Diagnostic Challenges: Bipolar Disorders and Other Mood Disorders. Po W. Wang, M.D.

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1 Diagnostic Challenges: Bipolar Disorders and Other Mood Disorders Po W. Wang, M.D.

2 Objectives 1. Recognize different episodes and subtypes of bipolar disorders 2. Understand potential differences between bipolar and unipolar depression 3. Understand how bipolar presents in children 4. Appreciate ways to improve quality of diagnosis 5. Different treatment priorities.

3 Why is Diagnosis Important? Bipolar diagnosis frequently missed On average, 10 years from first symptoms to accurate diagnosis Most common inaccurate diagnoses Unipolar depression (adult patients) Attention deficit/hyperactivity disorder (pediatric patients) Complications of inaccurate diagnosis Delayed treatment Ineffective treatment Mood destabilizing treatment (without mood stabilizers) Unipolar depression > antidepressants Attention deficit/hyperactivity disorder > stimulants

4 DSM IV IV TR Mood Disorders Major Depressive Disorder Dysthymic Disorder Bipolar I Bipolar II Cyclothymia Secondary (due to alcohol, drugs, or medical illnesses) Bipolar Not Otherwise Specified (NOS) DSM IV TR: Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Text Revision. Washington, DC, 2000.

5 Major Depressive Episode 5 symptoms for 2 wks: depressed mood* sleep change low interest/pleasure* weight / appetite change low energy activity change low self esteem / guilt poor concentration / indecisive death/suicide thoughts Distress, social/occupational impact Not mixed episode, simple grief Not due to alcohol, drugs, or medical illness * at least one of these symptoms required. DSM IV TR: Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Text Revision. Washington, DC, 2000.

6 Manic Episode Euphoric / expansive / irritable * 1 wk (or hospitalized) 3 ( 4 if merely irritable) additional symptoms for 1 wk: inflated self esteem decreased sleep need overtalkativeness racing thoughts distractibility hyperactivity impulsivity (spending, sexual) Severe Psychosis, hospitalization Marked social / occupational impact Not due to alcohol, drugs, or medical illness at least one of these symptoms required. Hypomania same criteria except duration 4 days, and not severe. DSM IV TR: Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Text Revision. Washington, DC, 2000.

7 DSM IV TR Bipolar Disorders Bipolar I Mania ± Depression Hypomania Bipolar II Depression Cyclothymia Mania (but not hypomania is Severe i.e. Entails Psychosis, Hospitalization, or Severe Impairment DSM IV TR: Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Text Revision. Washington, DC, 2000.

8 DSM IV TR Depressive Disorders Major Depressive Disorder Depression Dysthymic Disorder DSM IV TR: Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Text Revision. Washington, DC, 2000.

9 Possible Opposite Symptoms of Mania and Depression Mania Depression Mood Euphoric Sad Thoughts Racing Slowed Self esteem Inflated Deflated Speech Overtalkative Decreased Activity Restless Sluggish Decisiveness Impulsive Indecisive Sleep need Decreased Increased Appetite Decreased Increased Italics indicate non DSM symptoms. Ketter TA (ed.) Clinical Manual of Bipolar Disorders, Am Psychiatric Publishing, Inc., Washington, DC. (In Press).

10 Possible Simultaneous Symptoms of Mania and Depression Mania Depression Mood Irritable Decreased interest/pleasure Thoughts Distractible Poor concentration Activity Restless Restless Sleep Decreased need Decreased Ketter TA (ed.) Clinical Manual of Bipolar Disorders, Am Psychiatric Publishing, Inc., Washington, DC. (In Press).

11 Mixed Episode Manic + depressed 1 week Severe Psychosis Hospitalization Marked social/occupational impact Not due to Alcohol, drugs Medical illness DSM IV TR: Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Text Revision. Washington, DC, 2000.

12 Causes of Missed Bipolar Diagnosis Complex symptoms Irritable (rather than euphoric) mood elevation Hypomanic episodes may have enhanced function Mixed episodes can mimic agitated depression Depression most common symptom in bipolar Major depressive disorder most common inaccurate diagnosis Other disorders Attention deficit/hyperactivity disorder Substance use disorders, anxiety disorders Insufficient information Patients themselves may not recall or recognize mood elevation Ketter TA (ed.) Clinical Manual of Bipolar Disorders, Am Psychiatric Publishing, Inc., Washington, DC. (In Press).

13 Potential Differences Between Bipolar and Unipolar Depression Prior mania/hypomania Sex Illness Onset Episode Onset Number of episodes Postpartum episodes Psychotic episodes Activity Sleep Bipolar relative Unipolar relative Bipolar Yes Women = men < 25 years old Abrupt Many More More Sluggishness > restlessness Oversleeping > insomnia Common Common Unipolar No Women > men > 25 years old Gradual Few Less Less Restlessness > sluggishness Insomnia > oversleeping Uncommon Common Adapted from Akiskal HS. J Affect Disord 2005;84:

14 High Risk of Bipolar Outcome in Childhood and Severe Adolescent/Young Adult Depression Childhood Depression Adolescent / Young Adult Severe Depression 52% Not BP 33% BPI 59% Not BP 15% BPI 26% BPII 15% BPII Geller B, et al. Am J Psychiatry 2001;158: Goldberg JF, et al. Am J Psychiatry 2001;158:

15 Most Bipolar Disorder Patients Have Other Disorders As Well 80 Percent of Patients None 1 or more 2 or more 3 or more Number of Lifetime Other Disorders McElroy SL, et al. Am J Psychiatr. 2001;158:420 6.

16 Alcohol / Drug Use Disorders Overlap with Bipolar Disorders More Than Other Disorders Percentage of Patients with Alcohol / Drug Use Disorders % Bipolar I 48% 47% Bipolar II Schizophrenia 36% Panic Regier DA, et al. JAMA 1990;264: % OCD 31% Dysthymia 27% Unipolar Depression

17 Bipolar Outcome Increases with Number of Risk Factors (Early onset, Psychosis, Bipolar Relative) % Percentage Bipolar % Overall 27% 19% 49% 0 None One Two Three Number of Risk Factors Othmer E, et al. J Clin Psychiatry 2007;68:47 51.

18 Bipolar or Unipolar More Likely? Bipolar More Likely: Unipolar More Likely: Symptoms Oversleeping Insomnia Overeating Decreased appetite Sluggishness Restlessness Delusions or hallucinations Physical complaints Mood swings or elevation Onset and Course Onset age < 25 Onset age > 25 5 depressions total Current depression > 6 months Family History Bipolar disorder No bipolar disorder Adapted from Mitchell PB, et al. Bipolar Disord 2008;10:

19 How does mania present in kids? Warning Signs Risk taking behaviors with false beliefs of achievement Getting only a few hours of sleep but not feeling sleepy during the day (Children need 8 10 hours of sleep; Adolescents hours) Sneaking out of the house, running away, sexual activity, using drugs Energizer bunny My brain is going 100 miles/hour ; Jumping from topic to topic Grades getting worse from incomplete or unattempted school work Visits to the principal s office for behavior problems. Talking too much, being loud, hard to interrupt or understand

20 Mania: Kids versus Adults Resembles severe adult BD Many Daily Mood Swings Irritable and argumentative Euphoria Is Not As Common

21 Pediatric BD: Why Diagnosis is Difficult Depression comes before mania Symptoms of depression and mania occur at the same time Other diagnoses look like bipolar Other diagnoses occur at the same time. Treatment with lithium often does not work. 10x risk for suicide attempts than general population Strober M et al. J Affect Disord. 1988;15:

22 The Great Impersonator Severe form of attention deficit hyperactivity disorder (ADHD) Major depressive disorder Post traumatic stress disorder Substance induced mood disorder Pervasive developmental disorders Conduct disorder Schizophrenia/schizoaffective disorder Fetal alcohol effects/syndrome

23 Comparing Pediatric BD to ADHD BD ADHD Unstable Mood Internally distracted Can t soothe when angry Rage for hours Take big risks, look for danger or thrill Do better at school High energy/inappropriate giggling May be overly sexual Stable Mood Externally distracted Soothing helps Lose interest in fighting Do not intend to get into big trouble Do better at home Normal laughing or fun Sexuality not a major issue Family History ADHD meds can trigger mania No Family History ADHD meds help Worsen with Age Get better with Age

24 Improving Quality of Diagnosis Involve family / significant others in evaluation Consider Personal history of mania or hypomania Family history of bipolar disorder Use screening test Hirschfeld RM, et al. J Clin Psychiatry. 2004;65(suppl 15):5 9.

25 Mood Disorder Questionnaire Simple, self report screen for bipolar disorder Adolescent version also available A screening test not diagnostic clinical evaluation essential At Hirschfeld RMA, et al. Am J Psychiatry. 2000;157(11): ; Wagner KD, et al. J Clin Psychiatry. 2006;67(5):

26 FDA Approved Medications for Bipolar Disorder Acute Mania Acute Depression Prevention Year Drug 1970 Lithium 1973 Thorazine 1994 Depakote 2000 Zyprexa* 2003 Risperdal* 2004 Seroquel* 2004 Geodon 2004 Abilify* 2004 Equetro 2005 Depakote ER???? Asenapine *Add on and monotherapy Year Drug 2003 Symbyax 2006 Seroquel UNMET NEED Year Drug 1974 Lithium 2003 Lamictal 2004 Zyprexa 2005 Abilify 2008 Seroquel (adjunct) UNMET NEED Ketter TA (ed). Clinical Manual of Bipolar Disorder, Am Psychiat Pub, Inc., Washington, DC (In Press).

27 Antidepressants May Worsen Bipolar More Stable Mood Less Stable Mood Off (n = 4) TCA (n = 10) Off (n = 9) TCA (n = 4) Off (n = 2) Wehr et al. Am J Psychiatry ;145: TCA = Tricyclic Antidepressant

28 Treatment Differences Major Depressive Disorder (Unipolar Depression) Antidepressants Fluoxetine (Prozac) Sertraline (Zoloft) Paroxetine (Paxil) Citalopram (Celexa) Tricyclic Antidepressants Monoamine Oxidase Inhibitors Bipolar Disorder Mood Stabilizers Lithium Anticonvulsants Valproate (Depakote) Carbamazepine (Equetro, Tegretol) Lamotrigine (Lamictal) Oxcarbazepine (Trileptal) Topiramate (Topamax) Gabapentin (Neurontin) Zonisamide (Zonegran) New Antipsychotics Olanzapine (Zyprexa) Risperidone (Risperidal) Quetiapine (Seroquel) Ziprasidone (Geodon) Aripiprazole (Abilify) Clozapine (Clozaril)

29 Conclusions Challenging diagnosis due to Complex symptoms Pervasiveness of depression Confounding other disorders Insufficient information Improving diagnosis with Information from significant others Use of a screening instrument

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