This document discusses diagnosis and treatment of depression in bipolar affective disorder. It aims to differentiate bipolar depression from unipolar depression and borderline personality disorder. It reviews DSM-IV/V criteria for diagnosing manic, hypomanic, depressive and mixed episodes. It also discusses guidelines for treating bipolar depression, including psychosocial interventions and pharmacological options like mood stabilizers and antidepressants, noting debates around antidepressant use.

1. Depression in Bipolar
Affective Disorder
Diagnosis and Treatment
Dr Scott Eaton MBChB, MRCPsych, FRANZCP
@drscotteaton

2. • Disclosure

4. Goals:
• Understand the complexities of diagnosis
of Depression in Bipolar Affective Disorder.
Differentiate from depression in Bipolar,
unipolar depression and borderline
personality disorder.
• Introduction to the CANMET guidelines
for treatment of bipolar depression.
Review the debate regarding the use of
antidepressants.

5. DSM IV/V
• The diagnosis of BP I requires the following:
• A manic episode of at least 1 week’s duration that leads to hospitalization or other significant
impairment in occupational or social functioning
• The episode cannot be caused by another medical illness or by substance abuse
• Manic episodes also must include at least 3 of the following symptoms:
• Grandiosity
• Diminished need for sleep
• Excessive talking or pressured speech
• Racing thoughts or flight of ideas
• Clear evidence of distractibility
• Increased level of goal-focused activity at home, at work, or sexually
• Excessive pleasurable activities, often with painful consequences

6. • Hypomanic episodes are characterized by an elevated, expansive, or irritable mood of at least 4 days’
duration, along with at least 3 of the following symptoms:
• Grandiosity or inflated self-esteem
• Diminished need for sleep
• Pressured speech
• Racing thoughts or flight of ideas
• Clear evidence of distractibility
• Psychomotor agitation at home, at work, or sexually
• Engaging in activities with a high potential for painful consequences
• DSMV - “other specified”

7. • For major depressive episodes, the person experiences 5 or more of the
following symptoms for the same 2 weeks, with at least 1 of the symptoms
being either of the first 2 listed:
• Depressed mood
• Markedly diminished pleasure or interest in nearly all activities
• Significant weight loss or gain or significant loss or increase in appetite
• Hypersomnia or insomnia
• Psychomotor retardation or agitation
• Loss of energy or fatigue
• Decreased concentration ability or marked indecisiveness
• Preoccupation with death or suicide; patient has a plan or has attempted
suicide
• The symptoms cause significant impairment and distress
• The mood is not the result of substance abuse or a medical condition

8. • Mixed episodes are characterized by the following:
• Persons must meet the criteria for both mania and major depression; the
depressive event is required to be present for 1 week only (DSMV only 3
features required)
• The mood disturbance results in marked disruption in social or vocation
function
• The mood is not the result of substance abuse or a medical condition

10. Cases
• Typical presentations
• Small groups
• Formulate questions to help identify bipolar
depression or the primary differentials.

12. Unipolar vs Bipolar
• Why bother?
• Conundrum of over and underdiagnosis.
• Early intervention of the right sort.

13. • Forty et al - 2008 British Journal Psychiatry
• 593 UPD vs 443 BPD
• Lifetime psychopathology screening
• no UPD had bipolar/schizophrenia rel
• reviewed GP and psych case notes

14. Bipolarity Symptoms
• Psychosis 11vs30% p<.001
• Diurnal Mood variation 50vs60% p.003
• Hypersomnia 21vs43% p<.001
• More episodes of depression 4vs5 p.006
• Shorter episodes 26vs69weeks p<.001

15. Unipolar symptoms
• excessive self-reproach 96vs87% p<.000
• loss of energy p.05
• loss of libido 63vs35% p<.001

17. Personality Disorder
• Bassett 2012 ANZJP
• Review

18. • features of Borderline PD
• fear of abandonment
• impulsivity
• recurrent self-injurious behaviour
• affective instability
• episodic explosive rage/psychosis

19. • Disturbed Relatedness - identity
disturbance, emptiness, unstable
relationships.
• Behavioural Dysregulation
• Affective Dysregulation

20. Differences
• Family Hx of mood disorder - bipolar
• life trajectories - greater impact - bipolar
• ChildhoodTrauma
• Self-mutilation
• “Rapid” cycle vs Prolonged
• deficiency in mindfulness - borderline
• reduced self-control - borderline
• Depression - anger vs Depression - elation

21. Depressed Borderline
• Earlier age of onset
• greater frequency of depressive episodes
• greater “atypical features”
• comorbid anxiety
• substance abuse
• suicide attempts
• no bipolar family history

22. Text

23. Comorbidity
• Borderline - incidence 9% BPD I, 11% BPDII
• Bipolar 1 - Borderline 11%
• BipolarII - Borderline 16%
• Borderline better prognosis!!

26. • Guidelines first published in 2005
• updated in 07 and 09
• Multinational specialists with interest in
Bipolar Disorder

27. Facts:
• prevalence BP1 0.4%, BP11 1.4%
• lifetime suicide attempts - 1/3
• completed suicide 0.014 per 100person
years
• high work impairment

28. Chronic disease
management
• Educated clinicians = later relapse time
• frequent monitoring = better
social/occupational function
• symptom checklist = earlier recognition of
EWS

29. Psychosocial
• Group psychoeducation
• Interpersonal Psychotherapy
• CBT
• Internet BasedTherapy
• improvements in acute depression, long term
maintenance, hospitalization, function, adherence.
• Family FocusedTherapy improved well being in carers

32. Bipolar Depression:
Pharmcology
• First Line Treatments: (dose increase/change treatment 2-3/52)
• Lithium
• Lamotrigine
• Quetiapine , XR
• Combinations:
• Lithium/Valproate + SSRI (Not Paroxetine)
• Olanzapine + SSRI (not P)
• Lithium +Valproate
• Lithium/Valproate + buproprion

33. • Second Line Treatments
• Valproate
• CombinationTherapy
• Quetiapine + SSRI
• + modafinil
• Lithium/valproate + lamotrigine

34. • Third LineTreatments
• Carbamazepine
• ECT
• Olanzapine
• CombinationTherapy
• Lithium + Carbamazepine
• Lithium/valproate +Venlafaxine
• Lithium + MAOI/TCA
• Lithium + Pramipexole
• Lithium/CBZ/Valp + SSRI +Lamotrigine
• Quetiapine + SSRI

35. Not Recommended
• Gabapentin
• Aripiprazole
• Ziprasidone
• Combination:
• + ziprasidone
• + levetiracetam

36. • “Novel Therapies”
• EPA
• NAC
• Pramipexole

37. Bipolar II Depression
• First:
• Quetiapine, XR
• Second:
• Lithium, Lamotrigine,Valproate
• Lithium/Valproate + antidepressant
• Lithium+Valpraote
• Atypical + antidepressant
• Third:
• antidepressant
• quetiapine + lamotrigine
• + ECT, +NAC, +T3

39. Antidepressants!!
• Most often used
• Some circumstances - good evidence for worse outcomes
(paroxetine/buproprion)
• Strong evidence better than placebo and low rate of
SWITCH
• Mood stabilizer reduce risk of switch
• Beware “mild switch”

40. • suggest:
• SSRI can be used first line WITH a mood
stabilizer
• Taper after 6-8/52 remission
• avoid TCA or SNRI
• Not in Mixed state or Rapid cyclers or
monotherapy

41. • The ISBD recommendations for acute treatment of a depressive episode in
bipolar disorder include the following:
• Adjunctive antidepressants may be used for an acute bipolar I or II depressive
episode when there is a history of previous positive response to
antidepressants.
• Adjunctive antidepressants should be avoided for an acute bipolar I or II
depressive episode with 2 or more concomitant core manic symptoms, in the
presence of psychomotor agitation or rapid cycling.
• For maintenance treatment, the following is recommended:
• Maintenance treatment with adjunctive antidepressants may be considered if a
patient relapses into a depressive episode after stopping antidepressant therapy.

42. • The recommendations for antidepressant monotherapy includes the following:
• Antidepressant monotherapy should be avoided in bipolar I disorder.Antidepressant monotherapy
should be avoided in bipolar I and II depression with 2 or more concomitant core manic symptoms.
• The recommendations for antidepressant use in mixed states include the following:
• Antidepressants should be avoided during manic and depressive episodes with mixed features.
Antidepressants should be avoided in bipolar patients with predominantly mixed states. Previously
prescribed antidepressants should be discontinued in patients experiencing current mixed states.