Bipolar Disorder

Snapshot

• A 21-year-old woman is brought to the emergency room by a police officer. She was found wandering around the streets talking very rapidly about her plans to become the CEO of large companies such as Amazon. She did not resist being brought it but continued to delineate her goals, including traveling the world, establishing the world’s best charity, and rescuing all orphans. When her physician was able to reach a family member, they report that she had been acting this way for 2 weeks. She had previously had episodes of depression, but recently she has been sleeping only 1 hour a day, has been easily distracted, and talked very rapidly about her grand plans. Her only medication is an anti-depressant.

Introduction

• Overview
  • bipolar disorder is characterized by episodes of mania and depression
    • treatment is mood stabilizers or atypical antipsychotics
    • bipolar I  
      • at least 1 manic episode, with or without a hypomanic or depressive episode
    • bipolar II 
      • hypomanic episode and depressive episode 
• Epidemiology
  • incidence 
    • lifelong prevalence range from 0.9-2.1%
  • demographics
    • mean age of onset is 21 years
    • women often cycle through manic and depressive episodes more frequently
  • risk factors
    • other mood disorders
• Pathogenesis
  • mechanism
    • may be a genetic susceptibility for bipolar disorder
• may be atrophy in the brain

Presentation

• Symptoms
  • mood may normalize between episodes, and patient may be fully functional during this time
  • using antidepressants may destabilize mood and trigger an episode of mania 
  • manic episodes (at least 1 week duration and causes marked impairment in function) or hypomanic episodes (at least 4 days duration and may not be severe enough to cause dysfunction) with 3 or more of the following
    • grandiosity
    • decreased sleeping
    • excessive talking and pressures speech
    • racing thoughts and ideas
    • distractibility
    • increased level of goal-focused activity at home, work, or sexually
    • excessive pleasurable activities
  • depressive episodes (2 weeks duration) with 5 or more of the following, including either depressed mood or loss of pleasure or interest in activities
    • depressed mood
    • loss of pleasure or interest in activities
    • weight loss or gain or appetite loss or gain
    • hypersomnia or insomnia
    • psychomotor retardation or agitation
    • loss of energy or fatigue
    • feelings of worthlessness or excessive guilt
    • decreased ability to concentrate or make decisions
    • preoccupation with death or suicide
  • either phase may have psychotic features
• Physical exam
• psychomotor agitation or depression

Differential

• Cyclothymic disorder
  • key distinguishing factors
    • presents similarly but with milder symptoms and lasts 2 years or longer
• numerous periods of hypomanic symptoms that do not meet criteria for hypomania and depressive symptoms that do not meet criteria for a major depressive episode 

Treatment

• Non-medical
  • psychotherapy
    • indications
      • may help decrease recurrence rates or help improve quality of life
  • inpatient admission
    • indications
      • suicidal behavior or psychosis
  • electroconvulsive therapy (ECT)
    • indications
      • refractory to medications
• Medical
  • mood stabilizers
    • indications
      • first-line
    • drugs
      • lithium
      • valproic acid 
      • carbamazepine
      • lamotrigine
  • atypical antipsychotics
    • indications
      • if there are features of psychosis
    • drugs
      • ziprasidone
      • quetiapine
      • risperidone
• aripiprazole

Complications

• Increased risk of suicide