1. Part I -- Bipolar BasicsPart I -- Bipolar Basics
Kurt Weber, PhDKurt Weber, PhD
kurt.weber@snc.edukurt.weber@snc.edu
Mental Health America – Brown CountyMental Health America – Brown County
Bemis International CenterBemis International Center
St Norbert CollegeSt Norbert College
May 13, 2008May 13, 2008

2.  “Manic-depression distorts moods and
thoughts, incites dreadful behaviors,
destroys the basis of rational thought, and
too often erodes the desire and will to live It
is an illness that is biological in its origins, yet
one that feels psychological in the experience
of it; an illness that is unique in conferring
advantage and pleasure, yet one that brings
in its wake almost unendurable suffering
and, not infrequently, suicide.

3.  “I am fortunate that I have not died from my
illness, fortunate in having received the best
medical care available, and fortunate in
having the friends, colleagues, and family
that I do.”
 Kay Redfield Jamison, PhD, An Unquiet Mind,
1995, p 6

4. Purpose of today…Purpose of today…
 Some foundation information that mentalSome foundation information that mental
health professionals and “consumers”health professionals and “consumers”
should know…should know…

5. Bipolar disorderBipolar disorder
 formerly known as manic-depressive disorder
 brain disorder
 causes unusual shifts in a person’s mood, energy, and
ability to function
 Some people alternate mania and depression,
others have episodes of mostly one kind
 Episodes vary in duration from days to years
 the symptoms of bipolar disorder are severe
 damaged relationships
 poor job or school performance
 suicide

6. good newsgood news
 treatable
 bipolar disorder can be treated, and people with
this illness can lead full and productive lives

7. Types of Bipolar DisordersTypes of Bipolar Disorders
 The classic form of the illness, which involves recurrent
episodes of mania and depression, is called bipolar I
disorder
 Some people, however, never develop severe mania but
instead experience milder episodes of hypomania that
alternate with depression; this form of the illness is called
bipolar II disorder
 When 4 or more episodes of illness occur within a 12-month
period, a person is said to have rapid-cycling bipolar
disorder
 Some people experience multiple episodes within a single
week, or even within a single day
 Rapid cycling tends to develop later in the course of illness
and is more common among women than among men

8. demographicsdemographics
 Approximately 23 million Americans suffer from
bipolar disorder
 National Comorbidity Study-Replicated (NCS-R)
 the lifetime prevalence of bipolar disorder is 51%
 National Epidemiologic Survey on Alcohol and
Related Conditions (NESARC)
 lifetime prevalence of bipolar I disorder of 33%
 Native Americans have the highest incidence
 Asians and Hispanics have the lowest
 World Health Organization (1990)
 bipolar disorder is the sixth leading cause of disability
worldwide among people 15-44 years old

9.  Studies suggest that bipolar disorder clients
will be fully symptomatic 8% of the time, and
symptomatic 59% of the time
 30% of bipolar clients have both manic and
depressive episodes
 32% have mixed manic and depression
 22% have only manic episodes
 10% have only mixed episodes

10. Depressive episodes in BDDepressive episodes in BD
 Depression
 most frequent episode
 episodes last longer (254 weeks) than manic
episodes (55 weeks)

11. comorbiditycomorbidity
 485% of bipolar clients will have an anxiety
disorder
 708% will have a personality disorder
 Suicidal ideation is also highly associated
with comorbid substance abuse
 There is a strong association of suicide
attempts and comorbid anxiety disorders

12. suicidesuicide
 NIMH (2000)
 Suicide is a significant risk in bipolar disorder,
the highest of any psychiatric disorder at 20%
 As many as 25-50% of clients will make a
suicide attempt
 Most suicidal ideation occurs during
depressed or mixed episodes

13. features and subtypes (Mays)features and subtypes (Mays)
Bipolar I Bipolar II
 Psychomotor retarded agitated or retarded
 Sleep hypersomnia insomnia/hypersomnia
 Suicide +++ ++++
 Switching to mania hypomania
 Gender m = f f > m
 Prevalence 1% 1-2%

14. mixed episodesmixed episodes
 50% of clients have mixed mania
 state of mind characterized by symptoms of both
mania and depression
 more common in bipolar children and women
 may feel agitated, angry, irritable, and depressed
all at once
 combines a high activity level with depression
 particular danger of suicide or self- injury

15. Rapid cyclingRapid cycling
 frequently recurring (4+ episodes/yr) treatment resistant
depression alternating with hypomanic/manic episodes
 most commonly seen in female clients and with bipolar II
disorder
 15-25% of clients
 early onset common
 not known whether antidepressants can initiate rapid
cycling
 Variations include
 ultra-rapid (1 day to 1 week)
 ultradian (<24 hours)
 continuous

16. gender issuesgender issues
 no gender difference in the incidence of bipolar I
 both have onset in puberty
 men may have a slightly earlier onset
 Manic episodes
 equal frequencies among men and women
 Women are more likely to be treated than men and
receive treatment earlier in the illness (NESARC)
 no evidence of difference in treatment
responsiveness to mood stabilizers

17. Women…Women…
 more frequent and more severe episodes of
depression
 more comorbidities
 anxiety, obesity, migraine, thyroid
 greater relative increase in AODA and suicide
 more rapid cycling and mixed states

18. Women with BD…Women with BD…
 have a high risk of anovulatory disorders and
polycystic ovary syndrome (PCOS)
 metabolic condition that occurs in 7-15% of
reproductive-aged women
 elevated androgens
 chronic anovulation
 insulin resistance
 elevated LDL with low HDL
 3x risk of endometrial cancer

19. pregnancypregnancy
 50% of women with bipolar disorder have the onset
of symptoms within 1 year of menarche (Mays)
 however, most are not accurately diagnosed until
they have had a child and developed postpartum
depression
 67% of bipolar women will have postpartum depression
 33-50% of postpartum depressions begin during
pregnancy and worsen postpartum
 Suicide risk for the new mother is 70x higher
during baby's first year of life if mother has
postpartum depression

20. risk factors andrisk factors and
warning signs for PPDwarning signs for PPD
 Previous postpartum depression (50-75%)
 Having a mood disorder - bipolar disorder
gives 25% risk
 Single motherhood
 Stressful events
 Substance abuse
 Mood disorder symptoms during pregnancy

21.  No psychotropic drugs are known to be safe for
pregnancy or breastfeeding
 however, bipolar disorder itself is also dangerous
for pregnancy due to
 substance abuse
 poor self-care
 suicide
 medication for bipolar reproductive-age females
 recall that 50% of pregnancies in the US are unplanned

22. CausesCauses
 “…has anyone found the true cause of
bipolar disorder? It would be wonderful to
say that X or Y was the cause, but the
answer is not that simple”

23. biopsychosocial modelbiopsychosocial model
 Most scientists believe that mental illnesses
are caused by a combination of several
factors working together
 In bipolar disorder, these factors are usually
divided into biological and psychological
causes
 In plain English, the main reasons mental
illness develops are physical (biological) and
environmental

24. genetic originsgenetic origins
 if one parent has bipolar illness, chances are 1:7 that their
child will
 however, there are relatively few studies of the heritability
of bipolar disorder
 why?
 numerous subtypes of the disorder
 categorical distinction between major depression and bipolar
disorder (the presence of one manic episode) that confounds all
genetic studies of depression since the disorders seem to be clearly
related at some level

25. so, what is inherited?so, what is inherited?
 neurotransmitter functioning!
 neurotransmitter system has received a
great deal of attention as a possible cause of
bipolar disorder
 some studies suggest that a low or high level
of a specific neurotransmitter such as
serotonin, norepinephrine or dopamine is
the cause

26.  other studies indicate that an imbalance of
these substances is the problem
 the specific level of a neurotransmitter is not as
important as its amount in relation to the other
neurotransmitters
 still other studies have found evidence that a
change in the sensitivity of the receptors on
nerve cells may be the issue

27. sounds like…sounds like…
 researchers are quite certain that the
neurotransmitter system is at least part of
the cause of bipolar disorder
 further research is still needed to define its
exact role

28. Typical course of BD (Mays)Typical course of BD (Mays)
 median age of onset is 19median age of onset is 19
 first episodefirst episode
 most likely to be mania in males, depression in femalesmost likely to be mania in males, depression in females
 Severe psychosocial stressors appear more important in theSevere psychosocial stressors appear more important in the
first episode than latter episodes, i.e. there is “kindling” tofirst episode than latter episodes, i.e. there is “kindling” to
stress – each episode requires less stress to occurstress – each episode requires less stress to occur

29.  90% of clients who have one manic episode will90% of clients who have one manic episode will
have anotherhave another
 Four years after remission of the first episode, 60%Four years after remission of the first episode, 60%
had relapsedhad relapsed
 Without treatment, bipolar clients will have 9-10Without treatment, bipolar clients will have 9-10
episodes in their lifetime, and each episode will lastepisodes in their lifetime, and each episode will last
1-4 months1-4 months
 The interval between episodes will diminishThe interval between episodes will diminish
(kindling to episodes)(kindling to episodes)
 Episodes will become more treatment resistantEpisodes will become more treatment resistant

30. The course of BD (NIMH)The course of BD (NIMH)
 Episodes of mania and depression typically
recur across the life span
 Between episodes, most people with bipolar
disorder are free of symptoms, but as many
as one-third of people have some residual
symptoms
 A small percentage of people experience
chronic, unremitting symptoms despite
treatment

31. without treatment…without treatment…
 natural course of bipolar disorder tends to worsen
 over time, a person may suffer more frequent
(more rapid-cycling) and more severe manic and
depressive episodes than those experienced when
the illness first appeared
 proper treatment can
 help reduce the frequency and severity of episodes
 help people with bipolar disorder maintain good quality
of life

32. Children and adolescents?Children and adolescents?
 Both children and adolescents can develop
bipolar disorder
 more likely to affect the children of parents who have the
illness
 children and young adolescents with the illness often
experience very fast mood swings between depression and
mania many times within a day
 Children with mania are more likely to be irritable and prone
to destructive tantrums than to be overly happy and elated
 Mixed symptoms also are common in youths with bipolar
disorder
 Older adolescents who develop the illness may have more
classic, adult-type episodes and symptoms

33. NIMHNIMH
 Bipolar disorder in children and adolescents can be
hard to tell apart from other problems that may
occur in these age groups
 irritability and aggressiveness
 can indicate bipolar disorder
 can be symptoms of
 attention deficit hyperactivity disorder
 conduct disorder
 oppositional defiant disorder
 other types of mental disorders more common among adults such
as major depression or schizophrenia
 Drug abuse also may lead to such symptoms

34. of course…of course…
 For any illness, however, effective treatment
depends on appropriate diagnosis
 Children or adolescents with emotional and
behavioral symptoms should be carefully
evaluated by a mental health professional
 Any child or adolescent who has suicidal
feelings, talks about suicide, or attempts suicide
should be taken seriously and should receive
immediate help from a mental health specialist

35. ImagingImaging
 New brain-imaging techniques allow researchers to take
pictures of the living brain at work, to examine its structure
and activity
 without the need or surgery or other invasive procedures
 magnetic resonance imaging (MRI)
 positron emission tomography (PET)
 functional magnetic resonance imaging (fMRI)
 the brains of people with bipolar disorder may differ from
the brains of healthy individuals
 may develop a better understanding of the underlying
causes of the illness
 may be able to predict which types of treatment will work
most effectively

36. NIMH clinical studiesNIMH clinical studies
 real-world studies
 Unlike traditional clinical trials
 multiple different treatments and treatment combinations
 include large numbers of people with mental disorders living in
communities throughout the US and receiving treatment across a
wide variety of settings
 Individuals with more than one mental disorder, as well as those
with co-occurring physical illnesses, are encouraged to consider
participating in these new studies
 Systematic Treatment Enhancement Program for Bipolar
Disorder (STEP-BD)

37. the whole pointthe whole point
 improve treatment strategies and outcomes
 evaluate how treatments influence other
important, real-world issues such as
 quality of life
 ability to work
 social functioning
 assess the cost-effectiveness of different
treatments and factors that affect how well
people stay on their treatment plans