Bipolar Disorder:
Journey Through Mania
and Depression
H.E. Logue, M.D.
Bias Disclaimer
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There is no pharmaceutical support for
this program.
I am active in the research field and
involved in clinical trials for most of the
major pharmaceutical companies.
Goals and Objectives
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Promote better understanding of the
following aspects of Bipolar Disorder:
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Prevalence
Recognition and Diagnosis
Understanding Risk Factors
Genetic Predisposition
Treatment Considerations
Co-morbid Conditions
Referral Consideration
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Victor Hugo
Edgar Allen Poe
Leo Tolstoy
Michelangelo
Ezra Pound
Charlie Pride
Sergey
Rachmaninoff
Patty Duke
Thomas
Eagleton
Thomas Edison
T.S. Eliot
Ralph Waldo
Emerson
William Faulkner
Eddie Fisher
F. Scott
Fitzgerald
Betty Ford
Harrison Ford
Stephen Foster
Sigmund Freud
King George III
Tipper Gore
Robert E. Lee
Vivian Leigh
John Lennon
Alexander
Hamilton
Joan Rivers
Norman
Rockwell
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Charles Schultz
King Saul
William
Tecumseh
Sherman
Neil Simon
Rod Steiger
William Styron
Alfred, Lord
Tennyson
King Herod
Nathaniel
Hawthorne
Ernest
Hemingway
Audrey
Hepburn
Howard
Hughes
Thomas
Jefferson
Joan of Arc
Lyndon Baines
Johnson
Danny Kaye
Ted Turner
Mozart
Larry King
Jessica Lange
Mark Twain
Mike Tyson
Jean Claude
Van Damme
Queen Victoria
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Mike Wallace
George
Washington
Robin Williams
Tennessee
Williams
Thomas Wolfe
Virginia Woolf
Lord Tennyson
Vincent van Gogh
Peter Tchaikovsky
F. Scott Fitzgerald
Charles Dickens
Robert Louis
Stevenson
Walt Whitman
Sylvia Plath
Marlon Brando
Art Buckwald
John Bunyan
Rodney
Dangerfield
Charles Darwin
King David
John Denver
Princess Diana of
Wales
Charles Dickens
Emily Dickenson
Theodore
Dostoevski
Jack Dreyfus
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Richard
Dreyfuss
Kitty Dukakis
Liza Minnelli
Carman Miranda
Marilyn Monroe
J.P. Morgan
Ralph Nader
Sir Isaac
Newton
Florence
Nightingale
Ozzy Osbourne
Dolly Parton
Boris Pasternak
George Patton
Jane Pauley
Pablo Picasso
Cole Porter
Abraham
Lincoln
Joshua Logan
Jack London
Greg Louganis
Martin Luther
Imelda Marcos
Ann Margaret
Herman Melville
Burgess
Meredith
Kurt Vonnegut
Vivian Vance
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Drew Carey
Dick Cavett
Ray Charles
Frederick Chopin
Winston Churchill
Dick Clark
Rosemary
Clooney
Kurt Cobain
Natalie Cole
Samuel Coleridge
Sheryl Crow
Irving Berlin
Steven Foster
Lord Byron
(George Gordon)
Noel Coward
Alexander the
Great
Edwin “Buzz”
Aldrin
Hans Christian
Anderson
Roseanne Barr
Ludwig Von
Beethoven
William Blake
Napoleon
Bonaparte
Prevalence
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Bipolar Disorder affects approximately 5.7 million adult
Americans
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The median age of onset for Bipolar Disorder is 25 years.
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An equal number of men and women develop Bipolar
Disorder and it is found in all ages, races, ethnic groups
and social classes.
Bipolar Disorder is the sixth leading cause of disability in
the world.
Bipolar Disorder results in 9.2 years reduction in
expected life span, and as many as one in five patients
with bipolar disorder completes suicide.
Bipolar Disorder Subtypes
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Classic Bipolar Disorder
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Bipolar I
Bipolar II
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Subtypes
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Cyclothymia
Major Depression Unipolar/Recurrent
Dysthymic Disorder
Bipolar NOS (Not Otherwise Specified)
Other Considerations
Rapid Cycling (part of Bipolar I)
 Post-partum Onset
 Seasonal Pattern Mood Disorders
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DSM-IV Criteria - Depression
Five or more of the following:
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Depressed mood
Diminished interest or pleasure in activities
Significant weight loss/gain or decrease/increase in appetite
Insomnia or hypersomnia
Psychomotor agitation or retardation
Fatigue or loss of energy
Feelings of worthlessness or excessive or inappropriate guilt
Diminished ability to think or concentrate, or indecisiveness
Recurrent thoughts of death, recurrent suicidal ideation
without a specific plan, or a suicide attempt or a specific
plan for committing suicide.
Diagnostic Dilemmas
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Secondary Depression
Depression with…
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Other psychiatric illnesses
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Schizophrenia
Anxiety
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Personality Disorders
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Panic disorder
Obsessive-compulsive disorder
Borderline
Compulsive
Post-traumatic stress disorder
Post-partum depression
Grief/depression
Practically any psychiatric disorder
Depression with…
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Organic/Medical Illnesses
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Hypothyroidism
B-12 deficiency
Folate deficiency
Tuberculosis
Myasthenia gravis
Diabetes mellitus
Hepatitis C
Cushing’s disease
Mononucleosis
Parkinson’s disease
CHRONIC FATIGUE SYNDROME
DSM-IV Criteria - Mania
Three or more of the following:
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Inflated self-esteem or grandiosity
Decreased need for sleep
More talkative than usual or pressure to keep talking
Flight of ideas or subjective experience that thoughts are
racing
Distractibility
Increase in goal-directed activity or psychomotor
agitation
Excessive involvement in pleasurable activities that have
a high potential for painful consequences
Mood Symptoms
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Euphoria/Mania
Depression (in mixed state)
Anxiety
Anger
Hostility
Irritability
Behavioral Symptoms
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Energized Activity
Diminished Need to/for Sleep
Impulsivity
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Anger with Violence
Elevated Libido
Diminished Inhibitions
Reckless Behavior
Cognitive Symptoms
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Racing Rapid Thoughts
Diminished Insight/Invincibility
Sensory Hyperacuity
Hallucinations
Delusions
Perceptual Distortions
Distractible Disorganized Thoughts
S-H-O-T
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S: Symptomatology
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H: History
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What is the history of the person? The history of the family? Is
there a family history of mood swings, mood disorders,
substance abuse in persons with mood disorders or Bipolar
diagnosis?
O: Ongoing illness
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Do the symptoms appear to be manic or depressed or repeated
episodes of depression or mania or continuing mood swings?
What is the progression of the illness? What is the course of the
disease? Does it continue to go on in a progression appearing as
a Bipolar disease course?
T: Treatment response
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If one looks at the response of the treatment one should get a
good deduction as to the nature of the illness.
Understanding Risk Factors
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Stress (major or prolonged)
Sleep Deprivation/Disruption
Alcohol (major problem)
“Recreational” Drug Use
Discontinuation of Medications
Loss or Perceived Loss (job, family, friends, finances, health,
etc.)
Interpersonal Conflict
Travel Across Time Zones
Mood-Altering Medications (benzodiazepines,
antidepressants, antipsychotics)
Death of Loved One or Friend
Inadequate Coping Skills
Early Dementia or Minimal Brain Damage
Treatment
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Depression vs. Bipolar Depression
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Depression: Pre-Modern Era
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Tincture of Time
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Insulin shock
Electric shock
Spiritual
Education and
Psychotherapy
Pharmacotherapy
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Physical
Social
Mental
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Somatic
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Depression: Modern Era
Prescribed trip to Europe
Activity
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1950’s – Tricyclics
1960’s – Tetracyclics, etc.
1990’s – SSRIs (Prozac,
Paxil, Zoloft)
SNRI (Wellbutrin)
SSNRIs (Effexor,
Remeron, Cymbalta)
Spiritual
Treatment Statistics
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Patients with Bipolar Disorder face up to ten years of coping
with symptoms before receiving an accurate diagnosis.
Nearly 9 out of 10 patients with bipolar disorder are satisfied
with their current medication(s), although side effects remain
a problem.
Participation in a Depression and Bipolar Support Alliance
patient-to-patient support group improved treatment
compliance by almost 86% and reduced in-patient
hospitalization.
Consumers who report high levels of satisfaction with their
treatment and treatment provider have a much more positive
outlook about their illness and their ability to cope with it.
Bipolar Disorder Type II (Depressed
Type)
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Incorporate all of the previous slide
Recent studies suggest antidepressants cause a
sooner relapse or conversion to mania
Treating the Bipolar component is equivalent to
casting both broken legs.
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Mood stabilizers
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Antidepressants
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Lithium – only drug proven to reduce suicide rate
1950’s – Richard Dreyfuss
1990’s – Depakote, Tegratol, Trileptal, Lamictal
Atypicals?
Bipolar Disorder Type I
(Manic and Depressive)
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Mania
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Antipsychotics
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1953 – Thorazine/chlorpromazine
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Zyprexa, Seroquel, Abilify, Risperdal, Geodon
Risk and Benefits
Anticonvulsants
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Risk and Benefits
Atypical Antipsychotics
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World’s first psychotropic medication
Could treat psychosis and mania
Other conventional antipsychotics followed
Depakote, Tegratol, Trileptal, Lamictal
Risk and Benefits
Electroconvulsive Therapy
Genetics
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Like the illness, a complicated topic…
Confounding issues:
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Hypersexuality
Family disintegration
Separation of siblings
Twins
Genetic Models
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Mendelian vs. Polygenic Models
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1
2
1
1
affected parents = 1 in 4 affected offspring
affected parents = 2 in 3 affected offspring
dizygotic/fraternal twin = 1 in 6 affected twin
monozygotoc/identical twin = 2 in 3 affected twin
Epistatic Model
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Number 22 is prominently mentioned (same gene as
schizophrenia
Gene 21q is also involved
Genes 18p and 18q also are involved