7. CATEGORICAL
WATER TIGHT
NO OVERLAPS
DISCRETE
PRESENCE OR
ABSCENCE
DIMENSIONAL
SINGLE OR MULTIPLE
FACTORS
PRESENT IN ALL
CLASSIFIED
ACCORDING TO
DEGREE
8.
9.
10.
11. DENOTES TWO
EXTREMES
EQUATES WITH MANIA
THE HIGH
PATIENT DENIES BEING
MANIAC
ACCEPTS DEPRESSION
EITHER MANIA OR
DEPRESSION
12.
13.
14. ITALIAN PSYCHIATRIST
WORKED INFLORENCE
DESCRIBED
CLASSIFICATION
MANIA,
MELANCHOLIA,DEMEN
TIA
15. German psychiatrist
Director of Sachsenberg mental hospital
Dysthymia mutabilis
Mixture of Dysthyma atra (Black depression)
and Dysthyma candida (low-level mania).
16. Saltpetriere Hospital
Paris
La folie circulaire
1951
Alternating Mania and
Melancholia
Different from Mania
and melancholia
17. French Psychiatrist
Collegue at
Saltpetriete
Claimed that he was
the first the describe
cyclic illness
Tussle with Falret
18. GERMAN PSYCHATRIST
INTRODUCED THE
TERM CYCLOTHYMIA
ASSOCIATE HECKER
CATATONIA
HEBEPHRENIA
23. Poles what is reality
Eca survey
Incidence of Bipolar disorder is
1.2% (1988)
Ratio of Unipolar : Bipolar is
4:1
RECENT
6.4% (Judd &Akiskal 2003)
24. % among psy patients
One third of Depressed outpatients (Cassano 1989)
45% of Depressed Outpatients (Benazzi 1997)
60% Depressed Ghaemi
25.
26.
27. BIPOLAR ILLNESS IS COMMONLY MISSED
48% INITIALDIAGNOSISWAS MISSED
54% DIAGNOSED AS UNIPOLAR DEP
34%AS BIPOLAR
AVERAGE ITTOOK 8YRSTO DIAGNOSEAS
BPD
28.
29.
30.
31.
32.
33.
34. FOLLOW UP OF PREPUBRTAL AND
ADOLESCENT DEPRESSION
62. DSM V
Better than DSM IV
MANIC, HYPOMANIC, DEPRESSVE EPISODE
No MIXED episode
NOS omitted
BIPOLAR I, II CYCLOTHYMIA, SUBSTANCE, OTHER
MEDICAL CAUSES
63. MIXED
MIXED FEAUTURES IS A SPECIFIER
DEPRESSIVE EPISODE WITH MIXED FEATURES-
Agitated Depression
MANIC OR HYPOMANC EPISODE WITH MIXED
FEATURES- Dysphoric Mania
65. OTHER SPECIFIED BIPOLAR AND
RELATED DISORDER
SHORT DURATION HYPOMANIC EPISODES AND
MAJOR DEPRESSVE EPISODES
HYPOMANIC EPISODES WITH INSUFFECIENT
SYMPTOMS AND MAJOR DEPRESSIVE DISORDER
HYPOMANIC EPISODE WITHOUT PRIOR
DEPRESSIVE EPISODE
SHORT DURATION CYCLOTHYMIA
66. Neurobiology OF MANIA AND BIPOLAR
DISORDER*
Ambiguous till date
Biogenic amine neurotransmitters:
Noradrenergic system:
NE turnover increase in the cortical and thalamic areas of BD subjects where
decrease in depression
• Serotogenic system:
Reduced 5-hydroxytryptamine (5- HT)1A receptor binding potential in raphe
and hippocampus- amygdala of brain in depressed patients
Dopaminergic system
• DA agonists are effective antidepressants and are able to precipitate
mania.
• D2 receptor found in caudate, putamen, nucleus accumbens, cerebral
cortex and hypothalmus is negativly coupled to adenylyl cyclase. Older
antipsychotics act through blockage of D2 receptors , which eventualy
result in extrpyramidal system (muscle rigidty , involuntry movement,
pseudoparkinsonism)
67.
68. Worldwide disorder
Age at onset : Adult , Children & Adolescent
Among the top 10 of GBD ( Global Burden of diseases)
Fifth / Sixth amongst reported disability
An under diagnosed and under treated disorder
Bauer in, eds Tasman et al 2003
69. Bipolar depression Disease Burden
Patients with onset in mid to late 20’s effectively
lose 9 years of life, 12 years of normal health
and 14 years of normal activity
Increase likelihood of divorce by 3 X
Montgomery SA, Cassano GB, Management of bipolar disorder, 1996 , p5
70. Bipolar depression Disease Burden
Years lived with disorder :
Depression > Mania / Hypomania
Comorbidity:
- Anxiety disorders : 52%
( Panic, GAD, Social Phobia )
- Substance abuse disorder : 39%
Suicide
- 10% to 19-20% , 15 -30 times > general population
- At least 25% will attempt suicide
- 80% suicide attempts / completed suicide occur in depressed phase
- High mortality rates fro natural causes
Montgomery SA, Cassano 1996, Harris 1997
Judd et al 2002,2003
71. Bipolar depression
Diagnosis
Obstacles :
1. Under diagnosis , misdiagnosis
2. Misdiagnosed as unipolar depression ( MDD )
3. Often treated symptomatically with antidepressant
drugs
4. Antidepressant drugs : Despite evidence that they
induce mania or rapid cycling, ADDs are the most
frequently prescribed medication
5. Management overlooked in favor of mania
Thomas A. M. Kramer : Medscape General medicine, 2004 ; 6 /2 :29
72. Bipolar depression
Underdiagnosis or misdiagnosis
Presentation :difficult to diagnose
1. Less dramatic
2. Inadequate data ( Poor history)
3. Type II presentations, absence of manic symptoms
4. Normal v/s hypomania ???
Thomas A. M. Kramer : Medscape General medicine, 2004 ; 6 /2 :29
Kemps et al : Psychiatric times , Vol XXIII /9 , Aug ’06
82. TREATMENT OF BIPOLAR
ANTI DEPRESSANTS
MOOD STABILIZERS
ANTIPSYCHOTICS
OTHER
rTMS
83. ANTI DEPRESSANTS IN BIPOLAR
ILLNESS
CONTROVERSIAL
COMMONLY USED
DIAGNOSED AS UNIPOLAR DEPRESSION
SOME ARE EFFECTIVE IN BPDEPRESSION
LESS EFFICAY THAN LITHIUM
NOT EFFECTIVE IN PROPHYLAXS
84. ANTI DEPRESSANTS
ANTIDEPRESSANT INDUCED MANIA
MIMICS MIXED PHASE
SUICIDALITY IS COMMON
AGITATION INCREASES
RAPID CYCLING
DESTABILISATION
89. Unique mode of action – Bidirectional mood stabilizer
Clozapine like profile as an antagonist at multiple
receptors
Moderate affinity for D2
Greater affinity for 5HT2 to D2 ratio
Modulates DA & other monoamine pathways with
antimanic and antidepressant properties
No appreciable affinity for muscarinic & cholinergic
90.
91.
92. Intermittent blockade of D2 receptors & 5HT2A antagonist
No EPS
No TD
No se serum prolactin
no menstrual irregularities
no galactorrhoea
no impotency
J Clin Psychiatry 2000;61(Suppl 8):31-33
Safest among all atypicals
96. BIPOLAR DISORDER IS MORE COMMON THAN
WE THINK
AVERAGE BIPOLAR DIAGNOSIS DELAYED BY
DECADE.
PEOPLE WITH BPD SEPND MORE TIME IN
DEPRESSION
SPECTRUM CONCEPT MAY ANSWER MANY
QUESTION
97. THE QUESTION IS NOT
WHETHER THIS DEPRESSION IS BIPOLAR OR
NOT?
BUT
HOW MUCH BIPOLAR THIS DEPRESSION IS?