BIPOLAR DISORDER- MANAGEMENT PSYCHIATRY.pptx

Bipolar disorders management, psychopathology

1. CONTINUOUS MEDICAL EDUCATION: BIPOLAR DISORDER PRESENTER: MALANI SHUBANA A/P MURALEETHARAN 09/01/2024 OUR CENTER HOSPITAL LABUAN DEPARTMENT OF PSYCHIATRY

2. Introduction - Bipolar affective disorder (previously known as manic depression) is one of the most common, severe, and persistent psychiatric illnesses. In the public mind, it is associated with notions of ‘creative madness’, and indeed it has affected many creative people— both past and present ( Oxford Handbook of Psychiatry 4 th edition)

3. How common is Bipola r disorder? - 46 million people around the world, including 2.8% of the U.S. population, have bipolar disorder. - One survey of 11 countries found the lifetime prevalence of bipolar disorder was 2.4%. The U.S. had a 1% prevalence of bipolar type I, which was notably higher than many other countries in this survey. ( Therapeutic Advances in Psychopharmacology , 2018)  - The average age of onset is 25 years old. (National Alliance on Mental Illness, 2017) - On average, bipolar disorder results in 9.2 years reduction in expected life span (National Institute of Mental Health, 2017). - The risk of suicide is high in people with bipolar disorder with 15% to 17% committing suicide. (Treatment Advocacy Center) - Up to 60% of people with any mental health disorder, including bipolar disorder, develop substance use disorders. (WebMD, 2006) - Of those with bipolar disorder, many report co-occurring health conditions, which are most commonly migraine, asthma, and high cholesterol. High blood pressure, thyroid disease, and osteoarthritis were also identified as high probability co-occurring health problems. ( The British Journal of Psychiatry,  2014)

4. DEFINITIONS Reference: Am Fam Physician.  2021, based on DSM 5

5. Reference from: An Update on the Diagnosis and Treatment of Bipolar Disorder, Part 1: Mania, Psychiatric Times, 2015 – based on DSM 5

6. BIPOLAR 1 DISORDER

7. DIAGNOSTIC CRITERIAS Note: Criteria A-D constitute a manic episode. At least one lifetime manic episode is required for the diagnosis of bipolar I disorder.

8. Note: Criteria A-'F constitute a hypomanic episode. Hypomanic episodes are common in bipolar I disorder but are not required for the diagnosis of bipolar I disorder.

9. Note: Criteria A-C constitute a major depressive episode. Major depressive episodes are common in bipolar I disorder but are not required for the diagnosis of bipolar I disorder.

10. A. Criteria have been met for at least one manic episode (Criteria A-D under “Manic Episode” above). B. The occurrence of the manic and major depressive episode(s) is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder.

11. Specify. With anxious distress (p. 149) With mixed features (pp. 149-150) With rapid cycling (pp. 150-151) With meianchoiic features (p. 151) With atypicai features (pp. 151-152) With mood-congruent psychotic features (p. 152) With mood-incongruent psychotic features (p. 152) With catatonia (p. 152). Coding note: Use additional code 293.89 (F06.1). With peripartum onset (pp. 152-153) With seasonal pattern (pp. 153-154)

12. BIPOLAR 2 DISORDER

13. DIAGNOSTIC CRITERIAS

14. * Specify current or most recent episode: - Hypomanic - Depressed * Specify if: With anxious distress (p. 149) With mixed features (pp. 149-150) With rapid cycling (pp. 150-151) With mood-congruent psychotic features (p. 152) With mood-incongruent psychotic features (p. 152) With catatonia (p. 152). Coding note: Use additional code 293.89 (F06.1). With peripartum onset (pp. 152-153) With seasonal pattern (pp. 153-154): Applies only to the pattern of major depressive episodes. * Specify course if full criteria for a mood episode are not currently met: - in partial remission (p. 154) - In full remission (p. 154) * Specify severity if full criteria for a mood episode are currently met: M ild (p. 154) Moderate (p. 154) Severe (p. 154) Coding and Recording Procedures Bipolar 2 disorder

15. Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders - Scientific Figure on ResearchGate.

16. During a depressive episode, the differential diagnoses include: • Depressive Disorder due to another medical condition • Substance induced depressive disorder • Major Depressive Disorder (MDD) • Adjustment disorder with depressed mood • Anxiety disorders • Schizophrenia or schizoaffective disorder In a manic or hypomanic phase, the conditions below need to be ruled out: • Substance induced bipolar disorder • Bipolar and related disorder due to another medical condition for example brain injury • Schizophrenia or schizoaffective disorder • Borderline personality disorder DIFFERENTIAL DIAGNOSIS REFERENCE: Management of Bipolar Disorder in Adults, Clinical Practice Guidelines Malaysia, 2014

17. - Bipolar 1 disorder: The 12-month prevalence estimate in the continental United States was 0.6% for bipolar I disorder as defined in DSM-IV. Twelve-month prevalence of bipolar I disorder across 11 countries ranged from 0.0% to 0.6%. The lifetime male-to-female prevalence ratio is approximately 1.1:1. - Bipolar 2 disorder: The 12-month prevalence of bipolar II disorder, internationally, is 0.3%. In the United States, 12-month prevalence is 0.8%. The prevalence rate of pediatric bipolar II disorder is difficult to establish. DSM-IV bipolar I, bipolar II, and bipolar disorder not otherwise specified yield a combined prevalence rate of 1.8% in U.S. and non-U.S. community samples, with higher rates (2.7% inclusive) in youths age 12 years or older. PREVALENCE – BASED ON DSM 5

18. Perspective on Etiology and Treatment of Bipolar Disorders in China: Clinical Implications and Future Directions - Scientific Figure on ResearchGate. Available from: https://www.researchgate.net/figure/Multifactorial-model-of-etiology-and-pathogenesis-for-bipolar-disorders_fig1_333150447 , 2018 ETIOLOGY

19. RELEVANT INVESTIGATIONS REFERENCE: Management of Bipolar Disorder in Adults, Clinical Practice Guidelines Malaysia, 2014

20. SCREENING TESTS

21. SCREENING TESTS

22. SCREENING TESTS REFERENCE: https://www.moodtreatmentcenter.com/wp-content/uploads/2021/01/hcl32.pdf

23. SCREENING TESTS REFERENCE: https://dcf.psychiatry.ufl.edu/files/2011/05/Young-Mania-Rating-Scale-Measure-with-background.pdf

24. TREATMENT PHARMACOLOGICAL - Acute manic phase - Depression phase - Maintenance phase NON PHARMACOLOGICAL - Electroconvulsive therapy (ECT) - Psychosocial interventions = CBT, IPRST, Group-based, Family oriented interventions, EWS REFERENCE: Management of Bipolar disorder in Adults, Clinical Practice Guidelines MOH, 2014

25. REFERENCE: Bipolar-Disorders_Adult-Guidelines-2019-2020, floridamedicaidmentalhealth.org

26. REFERENCE: Bipolar-Disorders_Adult-Guidelines-2019-2020, floridamedicaidmentalhealth.org

27. REFERENCE: Bipolar-Disorders_Adult-Guidelines-2019-2020, floridamedicaidmentalhealth.org

28. REFERENCE: Bipolar-Disorders_Adult-Guidelines-2019-2020, floridamedicaidmentalhealth.org

29. REFERENCE: Bipolar-Disorders_Adult-Guidelines-2019-2020, floridamedicaidmentalhealth.org

30. PHARMACOLOGICAL TREATMENT REFERENCE: Am Fam Physician. 2021; Bipolar Disorders: Evaluation and Treatment Based on Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder.  The diagnosis and treatment of bipolar disorder: decision-making in primary care. Prim Care Companion CNS Disord . 2014.

31. ELECTROCONVULSIVE THERAPY (ECT) - In contrast to pharmacological treatment in the management of BD, the evidence on efficacy and safety of ECT is limited. Despite this, the use of ECT is relatively common particularly in severe mania, refractory depression and refractory mania. - A recent SR by Versiani M et al., ECT showed high response rates in people with acute mania, depression and mixed with minimal effects on cognitive functions. - However, the recommendation for ECT in BD remains inconclusive considering the limited quality in methodology and heterogeneity between studies - The evidence for the benefit of maintenance ECT in BD is limited but clinical experience supports its use in patients with severe symptoms who are unable to tolerate or respond poorly to other forms of maintenance treatment. NON PHARMOCOLOGICAL TREATMENT REFERENCE: Management of Bipolar disorder in Adults, Clinical Practice Guidelines MOH, 2014

32. Cognitive Behavioural Therapy (CBT) - CBT is an intervention based on the principle that thoughts, feeling and behaviour are inter-related. Its aim is to train patients to identify, challenge and replace the unhelpful thoughts which are associated with undesirable mood states to more helpful ones. - CBT was found to be more efficacious when compared to Treatment As Usual (TAU) in two RCTs. In people with fewer than 12 episodes, it reduced recurrence rates of major mood episodes - In people who were mildly depressed or mildly manic, it improved depression, anxiety, mania and hopelessness - A recent SR indicated that new modalities of psychological approaches, namely Cognitive Remediation, Functional Remediation and Mindfulness-based interventions showed favourable outcomes in BD. PSYCHOSOCIAL INTERVENTIONS REFERENCE: Management of Bipolar disorder in Adults, Clinical Practice Guidelines MOH, 2014

33. Interpersonal Social Rhythm Therapy (IPSRT) - IPSRT teaches patients to regulate sleep-wake patterns, work, exercise, meal times and other daily routines in addition to having therapy addressing interpersonal issues. - IPSRT in the acute phase prolongs remission compared to Intensive Clinical Management (ICM). - In STEP BD programme , patients who were on regular medications combined with intensive psychosocial interventions consisting of either IPSRT, CBT or Family Focused Therapy (FFT) significantly improved their relationship functioning and life satisfaction compared to those receiving medications with brief psychoeducation following a bipolar depressive episode. - Similarly, patients who received intensive psychosocial interventions as mentioned above were more likely to remain well clinically and had significantly higher year-end recovery rates and shorter times to recovery when compared to those receiving an ordinary brief psychoeducational intervention. - Likewise, another SR indicated that augmentation of pharmacotherapy with either one of the psychotherapies mentioned above improved social functioning and reduced relapse prevention rates. REFERENCE: Management of Bipolar disorder in Adults, Clinical Practice Guidelines MOH, 2014

34. Group Psychoeducation/Group-based Psychotherapy - Group psychoeducation provides understanding of the illness and its management in order to increase treatment satisfaction and adherence. - It focuses on improving illness awareness, treatment compliance, early detection of prodromal symptoms or recurrences and lifestyle regularity. - A SR reported that over 5 years follow-up, patients in the psychoeducation had less recurrences, spent significantly less time acutely ill and had reduced number of hospitalization when compared to the control group. - This is supported by a RCT showing that patients in group-based intervention had reduced rate of relapse of any type and spent less time unwell compared to those in control group. REFERENCE: Management of Bipolar disorder in Adults, Clinical Practice Guidelines MOH, 2014

35. Family-oriented Interventions - This covers areas such as communication, problem solving skills and psychoeducation in order to manage stresses in the home environment leading to high levels of expressed emotion. - A Cochrane SR found a very limited role of family-oriented interventions. - Family Focus Therapy was superior to Family Crisis Management in preventing relapse but not improving in medication compliance and dropout rates. - Other findings on the family oriented interventions were inconclusive. REFERENCE: Management of Bipolar disorder in Adults, Clinical Practice Guidelines MOH, 2014

36. Early Warning Signal (EWS) - EWS interventions train the patients to identify and manage early warning signs of recurrence. The main aim is to intervene early and self-manage manic and depressive symptoms. - In a Cochrane SR, EWS intervention significantly prolonged time to first recurrence of any mood episodes, manic/hypomanic and depressive episodes when compared to TAU. - In addition, it improved patients’ functioning and reduced hospitalisation rates. REFERENCE: Management of Bipolar disorder in Adults, Clinical Practice Guidelines MOH, 2014

37. Bipolar disorder is one of the top 10 leading causes of disability worldwide. A recent meta-analysis showed that patients with BD “experienced reduced life expectancy relative to the general population, with approximately 13 years of potential life lost.” Additionally, patients with bipolar disorder showed a greater reduction in lifespan relative to the general population than patients with common mental health disorders, including anxiety and depressive disorders, and life expectancy was significantly lower in men with BD than in women with BD. A different meta-analysis showed that all-cause mortality in patients with BD is double that expected in the general population. Natural deaths occurred over 1.5 times greater in BD, comprised of an “almost double risk of deaths from circulatory illnesses (heart attacks, strokes, etc ) and 3 times the risk of deaths from respiratory illness (COPD, asthma, etc ).” Unnatural deaths occurred approximately 7 times more often than in the general population, with an increased suicide risk of approximately 14 times and an increased risk of other violent deaths of almost 4 times. Deaths by all causes studied were similarly increased in men and women. A more recent systematic review of the association between completed suicide and bipolar disorder showed an approximately 20- to 30-fold greater suicide rate in bipolar disorder than in the general population. PROGNOSIS REFERENCE: Bipolar Disorder; https://www.ncbi.nlm.nih.gov/books/NBK558998/ ; 2023