March 30 - Bipolar Disorder

Question 1

Why is bipolar disorder difficult to diagnose?

Answer 1

It can be very difficult to diagnose, it often looks like major depression. The underlying disorder may resemble an “extension” of severe depression or a hybrid and psychotic illness. It is especially difficult to diagnose if patients don’t recognize or devalue their hypomanic or manic episodes

Question 2

What causes bipolar disorder?

Answer 2

The exact etiology is unknown
Genetic factors are important, as is environmental influences
Neurochemical, anatomic, stressors, alcohol, substances, sleep-wake cycle distruption can elicit the “expression” of a predisposition for neurotransmitter and neuroendocrine dysregulation

Question 3

Describe the neurochemistry of bipolar disorder

Answer 3

There is evidence of imbalances/dysfunction of hormones, neuropeptides, and many neurotransmitters - including: dopamine, norepinephrine, serotonin, melatonin, GABA, glutamate, aspartate, actylcholine. Medications which decrease neuron excitability have been the most helpful

Question 4

Describe bipolar disorder

Answer 4

It presents as a range of deficits that may be consistent with an extreme variant of depression, or a mix of depression and psychosis, or the damage resulting from a prolonged excess of neurotransmitters (especially excitatory)

Question 5

Describe the depressed phase of bipolar disorder

Answer 5

Presentation may be in the mild to disabiling spectrum, similar to unipolar depression (so psychosis is possible). Often depressed episodes outnumber manic or hypomanic episodes, and are often of more intense concern to the patient. It is very different than unipolar depression.

Question 6

Why are antidepressants to be avoided when possible in bipolar disorder?

Answer 6

Antidepressants can switch a person from a depressive episode into a manic one

Question 7

What are the medications used in bipolar disorder?

Answer 7

Acute care may involve benzodiazepines and antipsychotics
Mood stabilizers have the best evidence for long-term benefit
Optimal long-term management may involve a mood stabilizer and an antipsychotic, with non-pharmacologic supports including sleep cycle management (very important)

Question 8

Describe the manic phase warning signs

Answer 8

Mood changes (elevated/expansive, irritability, easily “spiked”)
Increased energy/restlessness, decreased need for sleep
Rapid/pressured speech
Impaired judgement/impulsivity (e.g., sexual adventures, spending mass amounts of money)
Distractible, flight of ideas
Psychotic “flavor” is possible

Question 9

Describe a mixed episode

Answer 9

Simultaneous symptoms of depression and mania (e.g., frantic energy with hopelessness, guilt)
Anxiety and agitation are a concern in bipolar disorder, but most common if mixed there are mixed features. They may be highly visible or may be below the surface. This is a very dangerous time for the patient (important to protect them from suicide)

Question 10

What have neuroimaging studies shown?

Answer 10

Structural neuroimaging studies show abnormal myelination in several brain regions associated with bipolar disorder - possible link with the inability to “categorize”

Question 11

What are biochemical factors that need to be taken into account?

Answer 11

Drugs (both prescription and illicit) which increase neurotransmitters (serotonin, norepinephrine, dopamine) can trigger mania
Increased levels of glutamate have been observed in post-mortem samples
There is a significant hormonal and CRH imbalance
Anticonvulsants (and calcium channel blockers) can be effective treatments

Question 12

How are bipolar patients categorized?

Answer 12

Bipolar I and bipolar II. Both groups are subject to major depression. Bipolar I indicates at least one severe manic episode. Patients who experience less severe manic symptoms (hypomania) are considered bipolar II. Neither of these have any implications for drug treatment

Question 13

What improves the prognosis of bipolar disorder?

Answer 13

Overall history, lack of “rapid cycling”
Little or no psychotic features, substance abuse, medical problems, suicidal thoughts
Decent work history, shorter manic/depressive phases, absence of residual depressive symptoms when “well”

Question 14

What are mood stabilizers used in bipolar disorder?

Answer 14

Lithium
Anticonvulsants
Antipsychotics
Calcium channel blockers (?)

Question 15

How does lithium work as mood stabilizers?

Answer 15

Through two second-messenger systems (phosphatidylinositol and cAMP), membrane-mediated rsponses are slowed or “normalized”
It offsets the impact of “excessive” neurotransmitter release/activity

Question 16

How do anticonvulsants work as mood stabilizers?

Answer 16

Valproic acid antagonizes glutamate, agonizes GABA and supports neuroregenerative factors
Anticonvulsant effectiveness involves the “dampening” of excessive neurotransmission and neurotransmitters, leading to increased control over impulses and potential for normal fluctuations in mood to become pathologic episodes

Question 17

How do antipsychotics works as mood stabilizers?

Answer 17

Antipsychotic effects are quite beneficial in acute mania
The mood stabilizing effect of SGAs and FGAs has been demonstrated, but how serotonin antagonism and/or D2 antagonism translates to mood stabilizing effect is not clearly known
We do know that they work acutely and in maintenance treatment

Question 18

Explain the importance of adherence in bipolar disorder

Answer 18

Longer “stability” increases the resistance to both depressive and manic relapse
Long-term adherence to effective treatement is known to increase quality of life and reduce impact of illness
Real world - both medication adherence and sustained positive outcomes are rare

Question 19

What are Margaret Trudeau’s wellness tips?

Answer 19

Self-monitor, don't self-medicate
Don't try this alone
Find an exercise regimen
Get in touch with your spiritual side
Find a way to be needed