B i p o l a r D i s o r d e r

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1 B i p o l a r D i s o r d e r Professor Ian Jones Director National Centre for Mental Health /WalesMentalHealth

2 Robert Schumann

3 Schumann's works by year and opus number Suicide attempt Hypomanic throughout 1840 Severe depression throughout 1844 Goodwin & Jamison 1990, Hypomanic throughout 1849 Essentially euthymic except 1852 Suicide attempt Starved to death in asylum

4 Why is bipolar disorder important? As common as schizophrenia Causes significant morbidity and mortality Cost to UK economy estimated at 2billion annually (Das & Guest 2002) Leading cause of maternal death

5 Bipolar disorder the Cinderella of Psychiatry Under recognised Under and poorly treated Under researched Pub med search Bipolar disorder / manic depression: Schizophrenia: 99562

6 Plan of talk Flying tour of bipolar disorder Raise some issues about the impact on work Briefly cover what are we doing in Cardiff psychoeducation specific work module

7 Bipolar Disorder DEPRESSION Low mood Loss of enjoyment MANIA Elevated mood Irritability Fatigue Psychomotor retardation Insomnia Loss of appetite / weight Poor concentration Hopelessness Suicidality Goal directed activity Psychomotor agitation Reduced need for sleep Racing thoughts / speech Distractible Inflated self esteem Increased libido

8 mania hypomania Period lasting 1 week Sufficiently severe to cause marked impairment in social / occupational functioning May necessitate hospitalisation Possible psychotic features Period lasting at least 4 days Not severe enough to cause marked impairment in social or occupational functioning No need for hospitalisation No psychotic features

9 Depression Mania A Spectrum of Affective Disorders Normal fluctuation Unipolar Depression Bipolar II Bipolar I

10 Mixed affective episode Symptoms of depression and mania occur concurrently Difficult diagnostic and treatment problem Much more common than once thought Mania and depression are not polar opposites

11 Mood, Speech, Self-esteem, Libido, Energy Mania Depression Activity Sleep Irritability Concentration

12 Bipolar Disorder Symptoms are Chronic and Predominantly Depressive 1% 2% 9% 6% 32% 53% 50% 46% 146 bipolar I patients followed 12.8 years % of Weeks Asymptomatic Depressed Manic/hypomanic Cycling / mixed 86 bipolar II patients followed 13.4 years Judd L, et al. Arch Gen Psychiatry 2002;59: Judd L, et al. Arch Gen Psychiatry 2003;60:261-9.

13 Bipolar Disorder Euthymia Cognitive abnormalities Reduced response inhibition Executive deficits Reduced attention Impulsivity Poor problem solving

14 Bipolar Comprehensive Outcomes Study (Berk et al, 2007) N=216 patients First experience of any First major symptoms depressive episode First manic episode BIPOLAR DIAGNOSIS 5 YEARS Age YEARS First experience of depressive symptoms First seeks medical treatment

15 What is the problem?

16

17

18 Current diagnostic scheme: Bipolar Disorder 1% Unipolar Depression 20%

19 Current diagnostic scheme: Clinical reality Bipolar Disorder 1% Bipolar Spectrum 10% 10% Unipolar Depression

20 No zone of rarity between bipolar and unipolar Increasing manic symptoms MDD BP A B C D E

21 Manic symptoms are common, even in primary care depression (n=538 patients screened) 30.9% screen positive for possible bipolar disorder

22 Bipolar Disease and Employment 40% in full time employment and 15% in part time employment, 25% unemployed (Stang et al 2007). This compares to a much lower rate of employment in individuals with a diagnosis of schizophrenia (Perkins and Rinaldi 2002).

23 Bipolar and employment Predictors of employment: Cognitive defects Depression Level of education

24 Particular issues for BP disorder Episodic: long periods of euthymia Over performance At least two (probably 4) poles distinct clinical states May require different responses to each Lack of insight - grandiosity Work related factors can be particular triggers e.g. shift work

25 1. Offer structured education to every person and/or their carer at and around the time of diagnosis, with annual reinforcement and review. Inform people and their carers that structured education is an integral part of care NICE: Key priorities for implementation

26 Type II Diabetes

27 Parity of Esteem 24% of people with a mental disorder receive treatment compared to 94% of people with diabetes

28 Bipolar disorder The provision of information about the nature, course and treatment of bipolar disorder is important in promoting access to services, and understanding and collaboration between patients, close family members, paid and unpaid carers and healthcare professionals.

29 Bipolar disorder Psychological interventions Offer a structured psychological intervention (individual, group or family), which has been designed for bipolar disorder and has a published evidence-based manual describing how it should be delivered, to prevent relapse or for people who have some persisting symptoms between episodes of mania or bipolar depression.

30 Bipolar disorder Individual and group psychological interventions for bipolar disorder to prevent relapse should: provide information about bipolar disorder consider the impact of thoughts and behaviour on moods and relapse include self-monitoring of mood, thoughts and behaviour address relapse risk, distress and how to improve functioning develop plans for relapse management and staying well consider problem-solving to address communication patterns and managing functional difficulties.

31 Psychoeducation Focus on illness and its consequences Add on to medication not an alternative Gives information but it goes further Training and Empowering Tries to change habits, attitudes and beliefs Is not. Just normal medical practice Giving a booklet or a website address Self help

32 Colom et al. Arch Gen Psychiatry. 2003;60:

33

34 Our programme

35 Module Introduction What is bipolar disorder? What causes bipolar disorder? Medication Psychological approaches Lifestyle Monitoring mood and identifying triggers Early Warning signature Friends and families Bringing it all together

36 The key areas Illness awareness Early detection of prodromal symptoms Treatment adherence Substance abuse avoidance Inducing lifestyle regularity Work an important area not covered key issue to emerge from feedback

37 Cardiff Project

38 Bipolar and Employment Module Improving the communication, collaboration and coordination between key players Line managers /OH / health professionals / individuals with a diagnosis of bipolar

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