What are the three most important things you learned this week?
What questions remain uppermost in your mind?
Is there anything you did not understand?
Bipolar Disorder
Brian McCarthy, MSN, PMHNP-BC
Objectives:
Identify criteria for Bipolar Disorder as outlined in the DSM-V.
Identify diagnostic tools to help in the diagnosis of bipolar disorder.
Identify modalities for the treatment of mania.
Identify features of bipolar depression and its treatment
Identify features of mixed states and its treatment.
Identify feature of rapid cycling and its treatment.
What are your thoughts on bipolar disorder?
What is bipolar disorder and how do you understand it?
What gets in the way of understanding what it is?
What does “bipolar” actually mean—the key to understanding the disorder fully.
DSM-V
To be considered mania, the elevated, expansive, or irritable mood must last for at least one week and be present most of the day, nearly every day. To be considered hypomania, the mood must last at least four consecutive days and be present most of the day, almost every day.
DSM continued
During this period, three or more of the following symptoms must be present and represent a significant change from usual behavior:
Inflated self-esteem or grandiosity
Decreased need for sleep
Increased talkativeness
Racing thoughts
Distracted easily
Increase in goal-directed activity or psychomotor agitation
Engaging in activities that hold the potential for painful consequences, e.g., unrestrained buying sprees
DSM
The depressive side of bipolar disorder is characterized by a major depressive episode resulting in depressed mood or loss of interest or pleasure in life. The DSM-5 states that a person must experience five or more of the following symptoms in two weeks to be diagnosed with a major depressive episode:
Depressed mood most of the day, nearly every day
Loss of interest or pleasure in all, or almost all, activities
Significant weight loss or decrease or increase in appetite
Engaging in purposeless movements, such as pacing the room
Fatigue or loss of energy
Feelings of worthlessness or guilt
Diminished ability to think or concentrate, or indecisiveness
Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt
There is more than just the DSM
It is helpful to look at bipolar disorder as a spectrum
As such, there are many people who will not match up to the criteria.
Tools
The MINI 7.0
This screening tool is not free but it is not hard to get copies of and it is available for subscription.
SCID
Structured Clinical Interview for DSM Disorders.
Harvard Bipolar Index
Developed by Gary Sachs and others (Ghaemi) at Harvard. Validated by Aiken and Weisler in 2015. It looks at 5 domains:
Hypomania or mania
Age of onset of first mood symptoms
Illness course and other features generally only visible over time
Response to medications (antidepressants and mood stabilizers)
Family history of mood and substance use problems
In practice
See the actual index.
Why use these tools?
Greater reliability than just opinion.
They have been validated.
Why would we not use them?
Would you allow your pcp to diagnose you with diabetes without lab work? Just his/her opinion alone?
So you have a manic patient—what will you do?
What are the medications you know of that are first line treatments?
Most but not all of the atypicals.
Which ones would you avoid?
Anticonvulsants: Depakote, Carbamazepine.
Do you know how to dose?
Do you understand the lab work?
Lithium
Gold standard
Dose at bedtime if possible
Do you know the lab values key for using lithium in mania?
Non-pharmacological options?
Exercise
Dark Therapy
Classic dark therapy
Modified dark therapy with blue light filter glasses
Mania is resolved….now what?
What do you do with meds at this point?
Do you reduce?
Your patient has bipolar depression? Now what?
What are the meds with FDA approval for bipolar depression?
Seroquel
Symbyax
Latuda
Vraylar
They aren’t working….now what?
What are your options?
Make sure the diagnosis is correct?
Think about the inflammatory theory of depression!
Inflammatory theory of depression/bipolar
Elevated levels of pro-inflammatory cytokines (TNF) in some patients
Variations in inflammatory markers depending on mood state (manic, euthymic, or depressed)
Positive correlation between elevated CRP and manic symptoms
Antidepressants with serotonergic effects had lower efficacy in patients with high inflammatory markers
Anti-inflammatory augmentation agents may help in patients with high inflammatory markers
Dopaminergic and glutamatergic agents may have better effects
Less Common Treatment Options.
pramipexole
riluzole
amantadine/memantine
celecoxib
minocycline
T3 and T4
tamoxifen
Continued.
aspirin
omega 3 fatty acids (O3FA)
n-acetylcysteine (NAC)
dextromethorphan and memantine
statins
esketamine
TMS
light therapy
Mechanisms of Action.
pramipexole: dopamine agonist
amantadine/memantine: dopamine agonist, NMDA receptor blocker
celecoxib: anti-inflammatory
minocycline plus aspirin: anti-inflammatory
statins: HMG-CoA reductase inhibitor, lowers CRP
O3FA: potentially anti-inflammatory
Continued
Light box: modulates circadian rhythm
T3 and T4: metabolic regulation
esketamine: NMDA receptor blocker
NAC: increases glutathione
TMS: modulates neural processing
riluzole: glutamate modulator
Anti-inflammatories
celecoxib, minocycline/aspirin, NAC, aspirin, O3FAs, statins
Note: must use PPI with celexicob
Aligns with inflammatory theory of depression
Check high sensitivity CRP
Mostly small research studies but promising results
May be especially useful for patients who have comorbidities that these drugs could also help with
O3FAs should have at least 1.5 times as much EPA as DHA for depression treatment
Dopaminergic agents
Pramipexole, amantadine, memantine
Dopamine agonist activity
May be used in conjunction with other medications.
Miscellaneous
esketamine
riluzole
T3 and T4
TMS
Non-pharmacological interventions.
MIND diet – combines Mediterranean and DASH (anti-inflammatory)
Light therapy
10,000 lux, at least 12”x17”, 30 mins per day
Exercise
Blu-blocker glasses – use after 6pm
Dark therapy – used for manic symptoms
Mixed States.
a person may either be experiencing a manic episode with at least three symptoms of depression or on the contrary, a major depressive episode with at least three symptoms of mania.
Classic phrase “tired and wired.”
More susceptible to medication side effects.
Rapid Cycling
Four mood episodes in a calendar year
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