Article 1 Primary Psychiatry 16:12 (Suppl 10)
Goldberg, Joseph F. “Overall assessment of mixed episodes in bipolar disorder.”
Dr Goldberg is a clinical associate professor of psychiatry at The Mount Sinai School of Medicine
“…mixed episodes…often present with co morbid anxiety or substance misuse…”
Interesting comment: “Although DSM-IV recognizes mixed episodes as occurring ONLY(ed) bipolar I disorder…mixed polarity symptoms may be EQUALLY(ed) common in patients with bipolar II disorder.
He states: “syndromic mood states” are a constellation of signs and symptoms.
Think of mania or hypomania when there is “nocturnal hyperactivity.” Likewise, if the patient is “flooded with thoughts,” look for “accelerated thought processes.” Psychomotor agitation can also go hand in hand with self-destructive behavior.
Goldberg advises: utilizing a corroborative historian especially in adolescents or young adults. Why? A clinician may need all the help she can get to identify prior depression or manic/hypomanic events.
Ref: Birk et al “Bipolar mixed states: the diagnosis and clinical salience of bipolar mixed states. Aust NZ J Psychiatry.2005; 391. 215-221. Agitated depression may overlap with mixed episodes.
Differentiate between true anxiety, iatrogenic signs, akathisia, drug intoxication/withdrawal effects, psychomotor agitation, and acceleration suggestive of mania or hypomania. (a potpourri of possibilities).
Psychosis (delusions, hallucinations, or formal thought disorder) occur in a half or more of those with bipolar I!
Here’s a gem: “subsyndromal mania symptoms may be eclipsed by more prominent depressive features.” Such patients may demonstrate fewer mania symptoms than would meet the DSM-IV criteria for a full mixed episode, they may show distracted thinking, psychomotor agitation, flight of ideas, or racing thoughts.
Some resources: Clinical Monitoring Form (CMF; www.manicdepressive.org.)
Diagnosis of bipolar disorder is based on the comprehensive interview!
Another resource: Hirschfeld, RM et al. Development and validation of a screening instrument for bipolar spectrum disorder: the Mood Disorders Questionnaire. Am J. Psychiatry.2000; 157:1873-1875.
He debunks “mood destabilization.”
He adds: “…transmission of bipolar disorder is non-Mendelian, conferring only moderate importance to the categorical presence or absence of bipolar disorder in a first-degree relative.”
In a 15-year follow-up study of late adolescents hospitalized for unipolar depression, 45% met criteria for mania or hypomania!
Delineate identification of prominent mood disturbances in the absence of acute intoxication states. Look for loss of need for sleep, flight of ideas, or racing thoughts not “mood swings.”
Important factoids: “Age of onset, psychosis, high rate of recurrence with brief episodes, atypical depressive features, cognitive deficits, and family history…help differentiate unipolar from bipolar disorder….”
Article 2 (Primary Psychiatry 16: 12 ( Suppl 10)
Frye, Mark A, M.D. “Treatment guidelines for acute manic and mixed episodes of bipolar disorder.”
Doctor Frye is professor of psychiatry and director of the Mayo Mood Clinic and Research Program, Rochester, Minnesota.
“It is important to look at evidence-based data set to guide treatment selection for mood stabilization.”
Pearl: “ …rapid cycling, mixed mania, psychotic symptoms…influence medication selection.” ( bipolar disorder is highly co-morbid with Axis I, II, and III illnesses).
Pearl: …dysphoric mania predictive of nonresponse to lithium and better to divalproex.
Benzodiazepines CAN work: “…lorazepam and clonazepam can be successfully used as adjunctive anti manic agents to treat acute mania”
Lithium (narrow therapeutic index), valproate, carbamazepine for acute mania. Valproate and carbamazepine: mixed episodes and a growing small evidence-based potential for alcohol withdrawal symptoms or relapse
Dysphoric mood: Nay lithium, Yay divalproex.
Lamotrigene: Yay bipolar depression(FDA: maintainance); Nay Acute mania
Atypical antipsychotics: Acute, mixed episodes. However increased associated mortality
Co-morbidity: alcohol abuse/dependency: earlier onset, higher rates mixed, rapid cycling, impulsivity, aggressivity, suicidality, and treatment-emergent mania.
Article 3 ( Primary Psychiatry 16: 12 (Suppl 10)
Bowden, Charles L. “Maintenance treatment in bipolar disorder.”
Doctor Bowden is clinical professor of psychiatry and pharmacology at the University of Texas health Center, San Antonio.
Doctor Bowden advocates efficacy versus adverse effects. He stresses carefully evaluating the patient who frequently presents as depressed. Start with an anti manic drug. If the patient persists psychotic or develops manic symptoms, choose an atypical antipsychotic. He advocates lamotrigene or valproate rather than carbamazepine as they are better tolerated. If devalproex was the right drug for the acute problem, it also had better maintenance outcomes.
He realistically discusses the finding of “poor set-shifting, processing speed predicted by any antipsychotic use.” So the goal must be to achieve a good dose yet avoid cognitive dulling and psychomotor slowing.
He reports “poorer executive function on WCST categories in subgroups taking antipsychotics.”
Two articles address a matter very close to my heart and I will list them for your perusal:
Frangou S, et al. The Maudsley Bipolar Disorder Project: executive dysfunction in bipolar disorder I and its clinical correlates. Biol Psychiatry. 2005;58:859-864.
Altshuler LL, et al. Neurocognitive function in clinically stable men with bipolar I disorder or schizophrenia and normal control subjects. Biol Psychiatry. 2004;56:560-569.
Such issues of deteriorated cognitive function ( in this case related to antipsychotics) certainly can relate to “ unrealistic fear of side effects on the part of patients or the patient’s family.”
Bowden notes that outcomes are less positive if there is preexisting anxiety. He alludes to a new comprehensive scale, the Bipolar Inventory of Signs and Symptoms Scale (BISS).
Ed: His message is that it is not just mania or depression but also anxiety, irritability, or psychosis that is pivotal how this illness performs. This is why the majority of patients are treated with multiple medications during acute mania and maintenance care.
He cites Goldberg et al in their study, manic symptoms during depressive episodes in 1380 patients with bipolar disorder: findings from the STEP-BD. Am J Psychiatry. 2009;166: 173-181. More than 1000 entered the program depressed but more than 2/3 had clear manic symptoms especially distractability, activation, excessive energy, or risky-type behavior.
His summary: “All of the different features associated with bipolar disorder-depression, mania, irritability, anxiety and psychosis; cognitive symptomatology; and adverse effects from medications used to treat the disorder—makes for a complex challenge for the patient and the clinician.”
PS: Bowden warns: don’t forget “... attention over time to appropriate sleep hygiene practices.”
Article 4 (Primary Psychiatry 16:12 (Suppl 10)
Sajatovic, Martha. Medical comorbidity and recovery in individuals with bipolar disorder.
Doctor Sajatovik is Professor of psychiatry at Case Western University School of Medicine in Cleveland, Ohio.
She opines: “Medical conditions are the rule rather than the exception among individuals with bipolar disorder.”
The range for the co-occurrence of metabolic syndrome ranges from 20-50% or greater.
ED: This has always been one of my pet peeves: “Psychiatrists often tend to operate in a vacuum when they need to be in communication with primary care (givers) and colleagues.”
She warns us that there is actually a lot of medical co-morbidity in individuals with late-life bipolar disorder compared with rather low rates in the community. One such strong statistic is that bipolar disorder is present in 17% of geriatric patients presenting to psychiatric emergency departments (ed question: with metabolic syndrome?)
Although the incidence of adverse drug reactions in bipolar patients is actually low under forty, 20% of hospital admissions are due to adverse events over 80!
She warns: “ …illness does not go away or ‘burn out’ in late life.”
It is crucial to (1) Characterize the target symptoms; (2) Identify and characterize any medical co-morbidity (especially in the geriatric patient). (3) Treat (parsimonious and step-wise in the elderly). Nothing will remain static! (4) Review on an ongoing basis medications for their toxicity or withdrawal; (5) Incorporate nonpharmacologic interventions; (6) Have multidisciplinary coordination.
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