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Bipolar disorder
Presented by
Dr. Chandan N
Intern, Department of Psychiatry,
MIMS, Mandya
• Bipolar mood or affective disorder is
characterized by recurrent episodes of mania
and depression in the same patient at
different times.
• Earlier known as manic depressive psychosis
(MDP)
Types
• Bipolar I: Characterized by episodes of severe
mania and severe depression.
• Bipolar II: Characterized by episodes of
hypomania (not requiring hospitalization) and
severe depression.
Etiology
• Etiology is not known.
• Theories:
• Genetic hypothesis
• Biochemical theories
• Neuroendocrine theories
• Sleep studies
• Brain imaging
Genetic hypothesis
• The life-time risk for the first degree relatives
getting bipolar disorder is 25%.
• Children with one parent having bipolar
disorder has a risk of 27% of life time risk,
children with both parents having bipolar
disorder is 74%.
• The risk in monozygotic twins is 65% and
dizygotic twins is 20%.
Biochemical theories
• Catecholamine's abnormality
(norepinephrine, dopamine and serotonin) in
one or more sites at brain.
• Acetyl choline and GABA may also play a role.
• The effects of antidepressants and mood
stabilizers also provide additional evidence.
Neuroendocrine theories
• Mood symptoms are prominently present in
endocrine disorders like hypothyroidism,
Cushing’s disease, and Addison’s disease.
Sleep studies
• In depression, decreased REM latency (i.e.,
the time between falling asleep and the first
REM period is decreased).
• Increased duration of the first REM period.
• Delayed sleep onset.
Brain imaging
• CT scan, MRI scan of brain, PET scan and
SPECT have yielded inconsistent, but
suggestive findings.
• Findings include ventricular dilatation, white
matter hyper-intensities, and changes in the
blood flow and metabolism in prefrontal
cortex, anterior cingulate cortex, and caudate.
Clinical features
Depression Form:
- constantly feeling sad or
worthless
- sleeping too much or too little
- feeling tired and having little
energy
- appetite and weight changes
- problems focusing
- thoughts of suicide
Manic Form:
- increase in energy level
- less need for sleep
- easily distracted
- nonstop talking
- increased self confidence
- focused on getting things done,
but does not accomplish much
- is involved in risky activities
even though bad things may
happen
Clinical features (Contd.)
• A current episode can be
• Hypomanic
• Manic without psychotic symptoms
• Manic with psychotic symptoms
• Mild or moderate depression
• Severe depression without psychotic symptoms
• Severe depression psychotic symptoms
• Mixed or
• In remission
Bipolar disorder
Course of the disorder
• Earlier age of onset
• Average manic episodes last for 3-4 months, a
depressive episode lasts for 4-6 months
• With rapid institution of treatment symptoms of
mania are controlled within 2 weeks and of
depression within 6-8 weeks
• Rapid cyclers
• Ultra rapid cyclers
• Increased mortality almost 2 times the normal
population
Prognostic factors
• Good prognostic factors
• Acute or abrupt onset
• Typical clinical features
• Severe depression
• Well adjusted premorbid personality
• Good response to treatment
• Poor prognostic factors
• Co-morbid medical disorders, personality
disorders or alcohol dependence
• Double depression
• Catastrophic stress or chronic ongoing stress
• Unfavourable early environment
• Marked hypochondriacal features, or mood
incongruent psychotic features
• Poor drug compliance
Differential diagnosis
• Rule out organic causes (drug induced, dementia)
• Rule out acute and transient psychotic disorders,
schizo-affective disorders, and schizophrenia
• Rule out delusional disorders
• Rule out adjustment disorders with depressed
mood, generalized anxiety disorder, normal grief
reaction, and OCD (with or without secondary
depression)
Management
• Antidepressants
• ECT
• Lithium
• Antipsychotics
• Other mood stabilizers
Antidepressants
Antidepressant Equivalent dose to 25mg
imipramine
Usual therapeutic range
(mg/day)
Imipramine 25 150-300
Amitryptyline 25 150-300
Nortryptyline 25 150-300
Clomipramine 25 75-250
Fluoxetine - 10-60
Paroxetine - 10-40
Sertraline - 50-200
Escitalopram - 10-20
Mirtazepine - 15-45
Lithium
• Drug of choice for manic episode and
preventing further episodes in bipolar
disorder.
• 1-2 week period lag before appreciable
improvement.
• Usual dose 900-1500mg of LiCO3 per day.
• Low therapeutic index.
• Plasma levels >2mEq/L is toxic and 2.5-3mEq/L
may be lethal.
Lithium (Contd.)
• Acute symptoms of toxicity are muscle
twitchings, drowsiness, delirium, coma and
convulsions, vomiting, severe diarrhoea,
albuminuria, hypotension, cardiac arrythmia.
• Before starting lithium therapy CBC, ECG,
urine routine, RFT, TFT should be done.
Antipsychotics
• Risperidone, olanzepine, quetipine,
haloperidol and chlorpromazine can be used.
• Indications:
• Acute manic episode
• Delusional depression
Other mood stabilizers
• Sodium valproate (1000-3000mg/day)
• Carbamazepine (600-1600mg/day) and
oxcarbazepine
• Lorazepam and clonazepam
• Topiramate
• Lamotrigine
• T3 and T4 as adjuncts in rapid cyclers.
Bipolar disorder

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Bipolar disorder

  • 1. Bipolar disorder Presented by Dr. Chandan N Intern, Department of Psychiatry, MIMS, Mandya
  • 2. • Bipolar mood or affective disorder is characterized by recurrent episodes of mania and depression in the same patient at different times. • Earlier known as manic depressive psychosis (MDP)
  • 3. Types • Bipolar I: Characterized by episodes of severe mania and severe depression. • Bipolar II: Characterized by episodes of hypomania (not requiring hospitalization) and severe depression.
  • 4. Etiology • Etiology is not known. • Theories: • Genetic hypothesis • Biochemical theories • Neuroendocrine theories • Sleep studies • Brain imaging
  • 5. Genetic hypothesis • The life-time risk for the first degree relatives getting bipolar disorder is 25%. • Children with one parent having bipolar disorder has a risk of 27% of life time risk, children with both parents having bipolar disorder is 74%. • The risk in monozygotic twins is 65% and dizygotic twins is 20%.
  • 6. Biochemical theories • Catecholamine's abnormality (norepinephrine, dopamine and serotonin) in one or more sites at brain. • Acetyl choline and GABA may also play a role. • The effects of antidepressants and mood stabilizers also provide additional evidence.
  • 7. Neuroendocrine theories • Mood symptoms are prominently present in endocrine disorders like hypothyroidism, Cushing’s disease, and Addison’s disease.
  • 8. Sleep studies • In depression, decreased REM latency (i.e., the time between falling asleep and the first REM period is decreased). • Increased duration of the first REM period. • Delayed sleep onset.
  • 9. Brain imaging • CT scan, MRI scan of brain, PET scan and SPECT have yielded inconsistent, but suggestive findings. • Findings include ventricular dilatation, white matter hyper-intensities, and changes in the blood flow and metabolism in prefrontal cortex, anterior cingulate cortex, and caudate.
  • 10. Clinical features Depression Form: - constantly feeling sad or worthless - sleeping too much or too little - feeling tired and having little energy - appetite and weight changes - problems focusing - thoughts of suicide Manic Form: - increase in energy level - less need for sleep - easily distracted - nonstop talking - increased self confidence - focused on getting things done, but does not accomplish much - is involved in risky activities even though bad things may happen
  • 11. Clinical features (Contd.) • A current episode can be • Hypomanic • Manic without psychotic symptoms • Manic with psychotic symptoms • Mild or moderate depression • Severe depression without psychotic symptoms • Severe depression psychotic symptoms • Mixed or • In remission
  • 13. Course of the disorder • Earlier age of onset • Average manic episodes last for 3-4 months, a depressive episode lasts for 4-6 months • With rapid institution of treatment symptoms of mania are controlled within 2 weeks and of depression within 6-8 weeks • Rapid cyclers • Ultra rapid cyclers • Increased mortality almost 2 times the normal population
  • 14. Prognostic factors • Good prognostic factors • Acute or abrupt onset • Typical clinical features • Severe depression • Well adjusted premorbid personality • Good response to treatment
  • 15. • Poor prognostic factors • Co-morbid medical disorders, personality disorders or alcohol dependence • Double depression • Catastrophic stress or chronic ongoing stress • Unfavourable early environment • Marked hypochondriacal features, or mood incongruent psychotic features • Poor drug compliance
  • 16. Differential diagnosis • Rule out organic causes (drug induced, dementia) • Rule out acute and transient psychotic disorders, schizo-affective disorders, and schizophrenia • Rule out delusional disorders • Rule out adjustment disorders with depressed mood, generalized anxiety disorder, normal grief reaction, and OCD (with or without secondary depression)
  • 17. Management • Antidepressants • ECT • Lithium • Antipsychotics • Other mood stabilizers
  • 18. Antidepressants Antidepressant Equivalent dose to 25mg imipramine Usual therapeutic range (mg/day) Imipramine 25 150-300 Amitryptyline 25 150-300 Nortryptyline 25 150-300 Clomipramine 25 75-250 Fluoxetine - 10-60 Paroxetine - 10-40 Sertraline - 50-200 Escitalopram - 10-20 Mirtazepine - 15-45
  • 19. Lithium • Drug of choice for manic episode and preventing further episodes in bipolar disorder. • 1-2 week period lag before appreciable improvement. • Usual dose 900-1500mg of LiCO3 per day. • Low therapeutic index. • Plasma levels >2mEq/L is toxic and 2.5-3mEq/L may be lethal.
  • 20. Lithium (Contd.) • Acute symptoms of toxicity are muscle twitchings, drowsiness, delirium, coma and convulsions, vomiting, severe diarrhoea, albuminuria, hypotension, cardiac arrythmia. • Before starting lithium therapy CBC, ECG, urine routine, RFT, TFT should be done.
  • 21. Antipsychotics • Risperidone, olanzepine, quetipine, haloperidol and chlorpromazine can be used. • Indications: • Acute manic episode • Delusional depression
  • 22. Other mood stabilizers • Sodium valproate (1000-3000mg/day) • Carbamazepine (600-1600mg/day) and oxcarbazepine • Lorazepam and clonazepam • Topiramate • Lamotrigine • T3 and T4 as adjuncts in rapid cyclers.