BIPOLAR DISORDERS

Dr. Martha Gobena; MD, Assistant professor of psychiatry

July 12,2024
 TOPIC OUTLINE
• Introduction
• Epidemiology
• Neurobiology
• Clinical Presentation
• Diagnostic Classifications
• Differential Diagnosis
• Investigations
• References
INTRODUCTION

• Mood can be defined as a pervasive and sustained emotion or feeling

tone that influences a person's behavior and colors his or her
perception of being in the world

• Disorders of mood sometimes called affective disorders-make up an

important category of psychiatric illness consisting of depressive
disorder, bipolar disorder, and other disorders
 Cont.

• Depressive episodes alternating with mania or hypomania represent the

domain of bipolar disorders
Epidemiology
• In Ethiopia
• In a large community study bipolar prevalence was 0.5%
• In geographically and genetically isolated population group the
prevalence was1.8%
Epidemiology
Sex
• Bipolar I disorder has an equal prevalence among men and women
• Manic episodes are more common in men, and depressive episodes
are more common in women
• Women are more likely to present with a mixed picture
• Women also have a higher rate of being rapid cyclers, defined as
having four or more manic episodes in a 1 -year period
Epidemiology
Age
• Age of onset for bipolar I disorder ranges from childhood (as early as
age 5 or 6 years) to 50 years or even older in rare cases, with a mean
age of 30 years.
• Incidence of the depressive phase of bipolar disorder after childbirth
is relatively high.
Epidemiology
Race and Ethnicity
• Rates of mood disorders are lower in blacks and Hispanic than in
whites.
Marital Status
• Bipolar I disorder is more common in divorced and single persons
than among married persons.
Seasonal Factors
• Spring and fall are the peak times for depression, just as
summer is for mania.
Epidemiology
Socioeconomic and Cultural Factors
• Mood disorders can easily lead to unemployment, divorce, or low
income
• Bipolar II disorder patients tend to belong to higher social
classes
• Bipolar I disorder is more common in persons who did not graduate
from college
Etiology
• Genetic
• Neurobiological factors ;
• Neurotransmitters (dopamine, serotonin, NE,Ach, GABA, Glutamate)
• Neuroendocrine abnormalities
• structural & functional brain abnormalities
• Psychosocial factors ;
• Social support
• life events & interpersonal difficulties
Genetic Factors
• Family data indicate that if one parent has a mood disorder, a child
will have a risk of between 10 and 25% for mood disorder.
• If both parents are affected, this risk roughly doubles.
• The risk is greater if the affected family members are first-degree
relatives rather than more distant relatives.
• A family history of bipolar disorder conveys a greater risk for mood
disorders in general and, specifically, a much greater risk for bipolar
disorder.
Twin Studies
• These provide the most powerful approach to separating genetic from
environmental factors, or "nature" from "nurture."

• Considering unipolar and bipolar disorders together, these studies

find a concordance rate for mood disorder in the monozygotic (MZ)
twins of 70 to 90 % compared with the same-sex dizygotic (DZ) twins
of 16 to 35 %.
Psychosocial Factors
Life Events and Environmental Stress
• Stressful life events more often precede first, rather than subsequent,
episodes of mood disorders for both patients with MDD and bipolar I
disorder.

• The stress accompanying the first episode results in long-lasting

changes in the brain’s biology.
Sleep and Circadian Rhythm
• In bipolar disorder, mania is typically accompanied by disturbed sleep
and, in particular, a decreased need for sleep.
• Studies suggest that mania and hypomania may be triggered by sleep
deprivation in bipolar individuals.
CLINICAL PRESENTATION

• Mood disorders are characterized by pervasive dysregulation of

mood and psychomotor activity and by related biorhythmic and
cognitive disturbances

• The two basic symptoms in mood disorders are depression and mania
Mood Disturbances In Manic
Episodes
MOOD ELEVATION
The mood in mania is classically one of elation, euphoria, and jubilation,
typically associated with laughing, punning and gesturing.
LABILITY AND IRRITABILITY
The prevailing positive mood in mania is not stable, patients can become
extremely irritable and hostile
PSYCHOMOTOR ACCELERATION
Is characterized by overabundant energy and activity and rapid,
pressured speech.
FLIGHT OF IDEAS
Thinking processes are accelerated; associations are difficult to follow.
IMPULSIVE BEHAVIOR
Manic patients are typically impulsive, disinhibited
familiarity with total strangers and intrusive
Heightened interest in every new activity
Vegetative Disturbances In
Mania
Hyposomnia
Some patients may actually go sleepless for several days
This could lead to dangerous escalation of manic activity which
might continue despite physical exhaustion.
Inattention to Nutrition
weight loss may occur because of increased activity and neglect of
nutritional needs.
Hyper sexuality
may lead to sexual indiscretion
Cognitive Distortions
• Manic thinking is overly positive, optimistic, and expansive
• Grandiosity - inflated self-esteem and a grandiose sense of confidence
and achievements
• Lack of insight and poor judgment, engage in harmful activities and
non adherence with medication regimens during the manic phase
• Delusion formation- Grandiose delusions, delusions of assistance,
delusions of reference and persecution
• Delusions occur in 75 percent of all manic patients
Mood Disturbances in
Depressive Episodes
• A depressed mood and loss of interest or pleasure are the key
symptoms in depression.
• Generalized psychomotor retardation – most common
• Decreased rate and volume of speech
• Mood congruent delusions
Guilt, sinfulness, worthlessness, failure, poverty, persecution,
terminal somatic illnesses
• Non delusional rumination about loss, guilt, suicide, death
DIAGNOSTIC CLASSIFICATION
Bipolar I disorder
Bipolar II disorder
Cyclothymic disorder
Substance or medication induced bipolar and related disorder
Bipolar and related disorder due to another medical condition
Other specified bipolar and related disorder
Unspecified bipolar and related disorder
Bipolar I Disorder
• Typically begins in the teenage years, the 20’s or the 30’s
• The first episode of bipolar I disorder may be manic, depressive or
mixed.
• Three mode of onset
mild retarded depression or hypersomnia for few weeks or
months which then switches in to a manic episode.(common)
Severely psychotic manic episode with schizophreniform features
Several depressive episodes occur before the first manic episode
• Manic episode has a rapid onset and may evolve over a few weeks
• Untreated manic episode lasts three months
• 5 to 15 percent of those with bipolar disorder can be classified as
rapid cyclers.(four or more episodes per year)
• After a singles manic episode 90 percent of them are likely to have
another
• Poorer prognosis than compared to those with MDD.
Bipolar II Disorder

• More prevalent than bipolar I disorder.

• An average of 50 percent of persons with major depressive disorder have been
reported to conform to the bipolar II disorder pattern
Cyclothymic Disorder
• begins insidiously before 21 years of age
• frequent short cycles of subsyndromal depression and hypomania.
• Repeated romantic breakups or marital failures and Uneven
performance at school
• Characterized as dilettantes
• Polysubstance abuse occurs in as many as 50 percent of such persons
Major Depressive Disorder
Versus Bipolar Disorder
Early age at onset  High-density three-generation pedigrees
Psychotic depression before 25 years of age  Trait mood lability (cyclothymia)
Postpartum depression, especially one with Hyperthymic temperament
psychotic features Hypomania associated with antidepressants
Rapid onset and offset of depressive Repeated (at least three times) loss of
episodes of short duration (less than 3 efficacy of antidepressants after initial
months) response
 Recurrent depression (more than five ) Seasonality
 Depression with marked psychomotor  Bipolar family history
retardation Depressive mixed state (with psychomotor
 Atypical features (reverse vegetative signs) excitement, irritable hostility, racing
thoughts, and sexual arousal during major
depression)
Treatment of bipolar disorders
Foundations of management
• Diagnose and intervene early
• Base line investigations
• Treat the disorder not just the acute episode
• Treat acute episode to full remission
• Assess for and treat comorbidities
• Monitor for treatment adherence
• Monitor for emergence of mood symptoms and suicide risk
Basic parameters
• History: medical comorbidities like CVD, smoking, alcohol use,
pregnancy status
• Investigations: BMI, CBC, RFT, LFT, electrolytes ,TSH ECG
Treatment of bipolar disorder
• Pharmacologic treatment
• ECT
• Psychosocial intervention
Acute phase management
Treatment of
• Manic or mixed episode of bipolar disorder
• Depressive episode of bipolar disorder
Pharmacologic management
• Lithium
• Anticonvulsant mood stabilizers
• Atypical antipsychotics
• Benzodiazepines
Pharmacolog…cont
• Patients presenting at emergency with manic episode are agitated,
irritable, uncooperative, lack insight, verbally or physically aggressive
• Ensuring the safety of the patient and those around is a priority
• Move patient to less stimulus and comfortable area.
Pharmaco…cont
• To manage agitation and aggression: haloperidol IM and
benzodiazepine IV can be used
Benzodiazepines
• In emergency situation used for calming and provide time for mood
stabilizers
• They are not formally approved mood stabilizers
Lithium
• Classic mood stabilizer, proven effective in treating
manic episode ‘classic euphoric grandiose type’
• But slow onset of action needed to be supplemented
with atypical antipsychotics, anticonvulsant mood
stabilizers or benzodiazepines in the early phase
• Help prevent suicide in mood disorders
• Therapeutic level is 0.6 to 1.2mEq/L
• It has narrow therapeutic index and it requires
monitoring plasma drug level.
Lithium
Side effects of lithium
• GI- dyspepsia, nausea, vomiting and diarrhoea
• Weight gain
• Hair loss, acne
• Tremor, sedation
• Hypothyroidism
• Polyuria and polydipsia ( nephrogenic diabetes insipideus) and also
lead to reduction in GFR
Pre lithium work up: TSH, serum calcium, ECG, RFT
Anticonvulsant mood stabilizers
Sodium valproate
• Normal dose level 750-2500mg/day.
• Rapid oral dosing 15-20mg/kg from day one treatment shown rapid
response.
Anticonvulsant mo…cont
Sodium valproate side effects
• Sedation
• Thrombocytopenia, leukopenia
• Liver and pancreatic effect
• Foetal toxicity NTD
• Amenorrhea, PCOS, hyperandrogenism
• Obesity, insulin resistance
Pre valproate workup: CBC, LFT, BMI, urine HCG
Anticonvulsant mo…cont
Carbamazepine
• Used as second line mood stabilizer
• Treatment of bipolar disorder that did not respond to lithium
• 800-1200mg/day
• Induce hepatic enzyme hence induction of it’s own metabolism
and those of other drugs.
Anticonvulsant mo…cont
Side effects of carbamazepine
• Dizziness, diplopia
• Nausea, dry mouth
• Hyponatremia
• Sexual dysfunction,
• Agranulocytosis
Pre treatment tests: urea, electrolytes LFT, CBC
Antipsychotics
Typical ( first generation) antipsychotics
• Haloperidol
• Chlorpromazine
Atypical (second generation) antipsychotics
• Olanzapine
• Risperidone
• Aripiprazol
• clozapine
ECT in bipolar disorder
• Reasonable alternative in patients with life threatening inanition,
suicidality, psychosis or catatonia
• For sever treatment resistant
• For sever depression or mania during pregnancy.
Treatment of bipolar depressive
episode
• Optimize the dose of mood stabilizer that the patient is on.
• Antidepressant monotherapy is not recommended
• If antidepressants are used should be combined with mood stabilizers
Maintenance treatment
• Following remission of acute episode patients are at high risk of
relapse up to 6 months. This phase of treatment is also called
continuation phase also part of maintenance phase
• Medications for maintenance phase: lithium, valproate, lamotrigine,
carbamazepine
• It is recommended to use a medication that were effective in treating
the acute phase
Treatment of bipolar disorder in
pregnancy
• Women at reproductive age group need detail contraceptive and
fertility discussion.
• Pregnancy should be planned and in consultation with psychiatrist.
• Risk and benefits of continuing/discontinuing should be assessed.
• No mood stabilizer is clearly safe, mood stabilizing antipsychotics are
preferable alternatives
• First trimester exposure to lithium, valproate and carbamazepine
associated with greater birth defect.
• Risk of relapse during pregnancy if mood stabilizing agent is
discontinued is high, risk of relapse after delivery is also high
• Not stabilizing mood has risk to both the mother and
foetus(neonate)
Psychosocial intervention

• Psycho education regarding bipolar disorder

• Enhancing treatment compliance
• Promoting regular patterns of activity and sleep
• Anticipating stressors
• Identifying new episodes early and minimizing functional impairments
Prognostic indicators
Poor prognostic factors
• Premorbid poor occupational status
• Alcohol dependence
• Psychotic features
• Depressive features
• Inter episode depressive features
• Male gender
Better prognostic factors
• Short duration of manic episodes
• Advanced age of onset
• Few suicidal thoughts
• Few coexisting psychiatric or medical problems
Reference
• Kaplan & Sadock’s comprehensive text book of psychiatry 10th edition
• Kaplan & Sadock’s synopsis of psychiatry 12th edition
• Stahl’s essential psychopharmacology 4th edition
• The Maudsely prescribing guideline 13th edition
References
• Kaplan and Sadock’s Comprehensive Textbook Of Psychiatry, 10th
edition
• Kaplan and Sadock’s Synopsis of Psychiatry,11th edition
• Diagnostic and Statistical Manual of Mental Disorders DSM 5, 5th
edition
• Integrated Neurobiology of Bipolar Disorder
• Contemporary psychiatry in africa, a review of theory, practice and
research
THANK YOU