BIPOLAR DISORDER

1. By
Naga Swathi Sree Kavuri
Doctor of Pharmacy
BIPOLAR DISORDER

2. Bipolar Disorder’s Criteria
 According to the American
Psychiatric Association’s
Diagnostic and Statistical
Manual of Mental Disorders,
fifth edition (DSM-V);
“Bipolar Disorder is
characterized by the
occurrence of one or more
Major Depressive Episodes
accompanied by at least one
Manic Episode.”

3. What Is Bipolar Disorder?
 A mood disorder that alters:
Feelings
Thoughts
Behaviors
Perceptions
(Within episodes of mania and depression)
 Bipolar Disorder is previously known as Manic Depression

4. Clinical Presentations
 Most commonly
diagnosed between
ages of 18 and 24
 Mania, Hypomania,
Psychosis, depression

5. Characteristics of Mania
 Feeling of being able to do anything
 Little sleep is needed
 Feeling filled with energy
 Not caring about financial situations
 Delusions
 Substance abuse
 The DSM-V has a list of symptoms and three or more must be
present.

6. Characteristics of Hypomania
 Feeling of creativity
 Don’t worry about problems seriously
 Feeling as if nothing can bring you down
 Have confidence in yourself
 Similar to Mania except Hypomania is of lesser intensity

7. Characteristics of Psychosis
 Poor attention and concentration
 Suspiciousness
 Social withdrawal
 Feeling that things around you have changed
 Describing the diagnosis with psychosis is usually used to
clarify the severity of the state of the disorder

8. Characteristics of Depression
 Sleep more than you normally would
 Feeling of tiredness
 Crying uncontrollably
 Withdrawing from activities you once enjoyed
 Staying in bed for days
 Weight Loss/Weight Gain
 The DSM-V has a list of symptoms and five or more must be
present during the same two week period.

9. DSM Criteria
 A distinct period of abnormally and
persistently elevated, expansive, or irritable
mood
 DIGFAST acronym (at least 3 of 7
symptoms)

10. DIGFAST – Mental Status Exam
 Distractible
 Increased activity/psychomotor agitation
 Grandiosity/Super-hero mentality
 Flight of ideas or racing thoughts
 Activities that are dangerous or hypersexual
 Sleep decreased
 Talkative or pressured speech

11. The Two Sides of Bipolar Disorder
 Bipolar I
 Episodes of full mania
alternating with
episodes of major
depression
 Diagnosed in patients
typically in early 20’s
 Bipolar II
 Episodes of major
depression and
hypomania

12. Evaluation of Patient
 Make sure no other medical condition is causing
mood or thought disturbance
 Perform a physical examination
– Look for possibility of substance abuse
– Trauma to brain
– Seizure disorders
 Perform mental health evaluation
– Mental status examination (MSE)
 Assesses mood and cognitive abilities
 Safety of individual
 Examines forms of psychosis

13. Evaluation of Patient Cont…
 Subjective experience of patient
 Family’s psychiatric history

14. Prevalence
 Lifetime= 1%
 Males and Females = no difference
 Age = all ages
– Highest prevalence is in the 18 to 24 year age group
 First degree relatives = incidence of BP increases
 Affects roughly 1/100 adults
 Very little data about kids and teenagers
 Linked to disturbed electrical activity in the brain

15. Bipolar Disorder
Difficulties
(Griswold, 2000)
Children Adolescents Pregnancy
Planning of pregnancy is a
Necessity because of
Medication
Rapid cycling could occur
Symptoms similar to adults
Psychosis can be a
Presentation of BP.
Substance abuse can be
Present which makes
Diagnosis difficult
Hyperactivity is most
Common; Makes BP
Difficult to diagnose

16. What Causes Bipolar?
 No single cause may ever be found for bipolar
disorder. Among the biological factors observed in
bipolar disorder, as detected by using imaging cans
and other tests, are the following:
– Over secretion of cortisol, a stress hormone.
– Excessive influx of calcium into brain cells.
– Abnormal hyperactivity in parts of the brain associated with
emotion and movement coordination and low activity in
parts of the brain associated with concentration, attention,
inhibition, and judgment.

17. How Serious is Bipolar Disorder?
Risk for Suicide
– An estimated 15-20% of patients who suffer from bipolar
disorder and do not receive medical attention commit
suicide.
 In a 2001 study of Bipolar I disorder, more than 50% of
patients attempted suicide; the risk was highest during
depressive episodes.
 Patients with mixed mania, and possible when it is marked by
irritability and paranoia, are also at particular risk.
 Many young children with bipolar disorder are more severely ill
than are adults with the disorder. According to a study in 2001,
25% of children with the disorder are seriously suicidal.

18. Seriousness of Disorder Cont.
 Thinking and Memory Problems
– In a 2000 study, it was reported that bipolar
disorder patients had varying degrees of
problems with short- and long-term memory,
speed of information processing, and mental
flexibility.
(Medications used for bipolar disorder, however,
could have been responsible for some of these
abnormalities and more research is needed to
confirm or refute these findings)

19. Seriousness of Disorder Cont.
 Substance Abuse
– Cigarette smoking is prevalent among bipolar
patients, particularly those who have frequent or
severe psychotic symptoms. Some experts
speculate that, as in schizophrenia, nicotine use
may be a form of self-medication because of its
specific effects on the brain.
– Up to 60% of patients with bipolar disorder abuse
other substances (most commonly alcohol,
followed by marijuana or cocaine) at some point
in the course of their illness.

20. Seriousness of Disorder Cont.
 Effect on Loved Ones
– It is very difficult for even the most loving families
and caregivers to be objective and consistently
sympathetic with an individual who periodically
and unexpectedly creates chaos around them.
– Often family members feel socially alienated by
the fact of having a relative with mental illness,
and they conceal this information from
acquaintances.

21. Seriousness of Disorder Cont.
 Economic Burden
– In 1991, the National Institute of Mental Health
estimated that the disorder cost the country $45
billion, including direct costs (patient care,
suicides, and institutionalization) and indirect
costs (lost productivity, and involvement of the
criminal justice system.)
– In one major survey, 13% of patients had no
insurance and 15% were unable to afford medical
treatment.

22. Treatment of Bipolar Disorder
(a four phase process)
 Evaluation and diagnosis of presenting
symptoms
 Acute care and crisis stabilization for
psychosis or suicidal or homicidal ideas or
acts
 Movement toward full recovery from a
depressed or manic state
 Attainment and maintenance of euthymia

23. Treatments
 Inpatient Care
 Assess the patient
 Diagnose the condition
 Ensure safety of patient and others
– This care is necessary for:
 Psychotic features
 Suicidal or homicidal ideations

24. Treatments
 Antidepressant therapy
 Mood stabilizer
– Lithium carbonate
– Sodium divalproex
– Carbamazepine
 Antipsychotic Agents
– Risperidone
– Haloperidol

25. Treatments
 Electroconvulsive therapy (ECT)
– Inpatient basis
– Severe cases
– Patient requires hospitalization often
 Faster than medications for therapeutic responses
 Memory loss before and after treatments
 3-8 sessions
 Medications are still required in maintenance phase of
treatment

26. Mood Stabilizers
Mood Stabilizer Common Adverse
Effects
Doses Special Concerns
Lithium carbonate
(Eskalith CR,
Lithobid)
Lethargy or sedation,
tremor, enuresis,
weight gain, overt
hypothroidism occurs
in 5-10% of patients
300-600 PO tid/qid
Must be adjusted by
monitoring serum
level and patient
response
Hypothyroidism,
diabetes insipidus,
polyuria, polydipsia
Sodium divalproex/
valproic acid
(Depakote,
Depakene)
Sedation, platelet
dysfunction, liver
disease, weight gain
10-20 mg/kg/d
Must be adjusted by
monitoring serum
levels
Elevated liver
enzymes or liver
disease, bone
marrow suppression
Carbamazepine
(Tegretol)
Suppressed WBS,
dizziness,
drowsiness, rashes,
liver toxicity(rarely)
200 mg PO bid Must
be adjusted by
monitoring serum
blood levels
Drug-Drug
interactions, bone
marrow suppression

27. Mood Stabilizers Cont…
Gabapentin
(Neurontin)
Headache,
fatigue, ataxia,
dizziness,
sedation, weight
gain
Not established Withdrawal
seizures
Lamotrigine
(Lamictal)
Sedation,
dizziness, nausea
or emesis, diplopia,
ataxia, headache,
sleep disruption,
benign rash
Not established Stevens-
Johnson
syndrome
Topiramate
(Topamax)
Nephrolithiasis,
psychomotor
slowing,
somnolence
Not established Decrease doses
in liver or renal
impairment

28. Mood Stabilizers Cont…
Felbamate
(Felbatol)
Liver Disease,
photosensitivity
, headache,
somnolence
Not
Established
Aplastic
anemia
Vigabatrin
(Sabril);
Investigational
drug
Weight gain,
agitation,
insomnia
Not
Established
Unknown

29. Psychotherapy
 Is not an effective treatment by itself, but can
be used in addition to medication
Types of therapy include:
-cognitive behavior therapy
-psychoeducation
-interpersonal therapy
-multifamily support groups

30. Cognitive Behavior Therapy
 More effective with the depressive part of
bipolar disorder
 “…Involves identifying irrational thought
patterns and altering [them] to better reflect
reality” ***Activities such as “daily mood logs”
can help

31. Psychoeducation
 Learning signs and symptoms of his/her
disorder; what triggers mood alteration
 More useful for mania
---Being able to identify signs and symptoms of
mania is helpful in the prevention of a “full
blown manic episode”

32. Interpersonal Therapy
 Helps to improve social skills and thereby
provides patients with more stability in
interacting with others
 Activities include:
- role playing
- modeling
- “guided in vivo practice”

33. Multi-family Therapy
 Parent involvement in a child with BD by
teaching the child:
-relaxation techniques
-anger management
-decision-making skills
-communication/listening skills
-seeing that children don’t become “victims of
their illnesses”

34. An Alternative Combination
 A combination of lithium and valproate can
be effective in treatment if monotherapy fails.

35. Treatment for Children and
Adolescents
 Lithium is one of the original treatments for bipolar
states in youth
 In a study in which chlorpramzine (thorazine) was
used, approximately 30% to 50% of youths had an
improvement with mood stabilizing
 In Frazier et al’s 2001 experiment, an eight week
study of using olanzapine monotherapy in 23
children and adolescents shown that there were
significant improvements of mania and depression
on doses ranging from 2.5 mg/day to 20 mg/day

36. Treatment Trends in the Elderly
 The number of new lithium users per year fell
from 653 to 281 in 2001 for older patients
 The number of divalproex users rose from
183 in 1993 to 1090 in 2001
 Though there has been a decline in elderly
lithium patients using lithium, lithium will
continue to be a mainstay until other mood
stabilizers are researched more extensively

37. Works Cited
Bipolar Disorder. (2002). Well Connected A.D.A.M. Inc. Retrieved from www.well-connected.com .
Dinan, Timothy G. (2002, April 27). Lithium in bipolar mood disorder. British
Medical Journal, 324 (7344), 898-991.
Griswold, Kim S. (2000, September). Management of Bipolar Disorder. American Family Physician.
www.findarticles.com/cf_0/m3225/6_62/65286755/print.jhtml
Hirshfeld, R., Clayton, P.J., Cohen, I., Fawcett, J., Keck, P., McClellan, J., et al. (2000). Practice Guidelines for
the Treatment of Patients With Bipolar Disorder. American Psychiatric Association Practice Guidelines for
the Treatment of Psychiatric Disorders, Compendium 2000, 503-562.
Nathan, Peter F., Gorman, Jack M. (1998). A guide to treatments that work.
New York: Oxford University Press.
Schlozman, Steven C. (2002, November). The Shrink in the Classroom. An Explosive Debate: The Bipolar
Child. Association for Supervision and Curriculum Development. (89-90).
Shulman, Kenneth I. (2003, May 3). Changing prescription patters for lithium
and valproic acid in old age: Shifting practice without evidence. British Medical Journal, 326
(7396), 960-962.

38. THANK YOU