Unipolar, Bipolar or
Borderline:
How do you tell what’s what…
A Guide for Clinicians
John P. Hendrick, M.D., DFAPA
Associate Professor of Psychiatry, ETSU
Chief, Inpatient Psychiatry, Mountain Home VAMC
Site Coordinator for Psychiatric Residency - VA/ETSU
Residency Training Coordinator for Neurosciences and
Psychopharmacology
Facts about depression
• Affects about 10% of the U.S. population with nearly three out of
four in the workplace (Gemignani, 2001) – Incidence
• 15 to 25% of the overall population - Prevalence
• Prevalence among school age children and adolescents is 4.6%
(Wagner, 2003)
• Millions do not seek treatment due to inadequate benefits and the
stigma associated with depression (U.S. Surgeon General, 2000)
• < 25% under the care of a mental health specialist
• Twice as common in women
• Peak incidence during primary reproductive years (25 to 45 yrs)
• Effective pharmacotherapy combined with psychotherapy has been
shown to reduce healthcare costs and the rate of suicide attempts
(Ballenger, 1999)
• Average disability length as well as disability relapse are greater for
depression than most comparison medical groups (Conti and
Burton, 1994)
How can a primary care doc
make a reasonable psychiatric
differential diagnosis?
• Language:
– Symptoms
– Diagnostic categories
• DSM-IV:
– 6484 signs, symptoms, inclusion criteria
– 405 diagnoses
– 18 diagnostic categories
• DSM-IV PC starts the process but is inefficient
and “psychiatric”
Mood Disorders
• Major Depression
– Single episode
– Recurrent
• Dysthymia
• “Double” Depression
• Bipolar Disorder
– Mania
– Hypomania (Type II ?)
• Psychotic Depression
(especially post partum psychosis)
• Depressive Disorder
NOS (Seasonal Affective
Disorder)
• Cyclothymia
• Mood Disorder
secondary to GMC
• Substance-Induced
Mood Disorder
• Adjustment Disorder
(separate classification)
Common Causes of Depression
CHAIN OF EVENTS
• Stress & loss
• Biological depression
• Physical illness and
its treatment interact
with depression in older adults
Recent Loss
___ recent relocation?
___ change in relationships?
___ change in health?
___ change in functional abilities?
___ change in sensory status?
___ change in financial status?
___ death of loved one? (even a pet)
___ loss of control over daily routines?
___ loss of significant role, change in social status?
___declining social contacts due to health limitations
EPISODE OF DEPRESSION
RECOVERY OR
REMISSION
NORMAL MOOD
DEPRESSION
TIME
6 - 24 months
5-1
Stahl S M, Essential
Psychopharmacology (2000)
Major Depression – Questions:
• How is your mood?
• Have you been feeling
sad, blue or depressed?
• Have you lost interest in
or do you get less
pleasure from the things
you used to enjoy?
• Has there been any
change in your appetite?
(5% weight change in 1
month)
• How have you been
sleeping?
• How has your energy
level been?
• Have you been more
fidgety?
• Have you felt slowed
down, like you were
moving in slow motion or
stuck in mud?
• How have you been
feeling about yourself?
• Have you been blaming
yourself for things?
• Have you had problems
thinking or concentrating?
Major Depressive Disorder (MDD)
• >2 week period of
change in behavior with
5 of the following:
–
–
–
–
–
*depressed mood
*anhedonia
appetite disturbance
sleep disturbance
psychomotor
disturbance (sluggish
behavior, tearfulness)
–
–
–
–
fatigue or loss of energy
worthlessness or guilt
impaired concentration
suicidal thoughts
• * 1/5 symptoms must
be these
• Rule out physical causes
MINOR Depression (Dysthymia)
People with this illness are mildly depressed for years. They function fairly
well on a daily basis but their relationships suffer over time.
• Also known as
– subsyndromal
depression
– subclinical depression
– mild depression
• 2 - 4 times more
common than major
depression
• Associated with:
– subsequent major
depression
– greater use of health
services
– reduced physical,
social functioning
– loss of quality of life
• Responds to same
treatments!
NORMAL
MOOD
DYSTHYMIA
DEPRESSION
2+ years
5-7
Stahl S M, Essential
Psychopharmacology (2000)
DOUBLE DEPRESSION
NORMAL
MOOD
DYSTHYMIA
2+ years
5-8
DEPRESSION
PARTIAL RECOVERY
6 - 24 months
Stahl S M, Essential
Psychopharmacology (2000)
Depression. It’s not only a state of
mind.
The symptoms of depression
Emotional Symptoms Include:
Physical Symptoms Include:
Sadness
Vague aches and pains
Loss of interest or pleasure
Headache
Overwhelmed
Sleep disturbances
Anxiety
Fatigue
Diminished ability to think or
concentrate, indecisiveness
Back pain
Excessive or inappropriate guilt
Significant change in appetite
resulting in weight loss or gain
Reference: Adapted from
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders.
Fourth Edition ,Text Revision. Washington, DC; American Psychiatric Association. 2000:345-356,489.
Pain perception
•
•
•
•
“Is it all in my head?”
Emotional aspects of pain
Biology of pain perception
Cultural factors
Depression – the physical presentation
In primary care, physical symptoms are often
the chief complaint in depressed patients
In a New England Journal of Medicine
study, 69% of diagnosed depressed
patients reported unexplained physical
symptoms as their chief compliant1
N = 1146 Primary care patients with major depression
Reference:
1. Simon GE, et al. N Engl J Med. 1999;341(18):1329-1335.
The importance of emotional and
physical symptoms
• 76% of compliant depressed
patients with lingering
symptoms of depression
relapsed within 10 months1*
94% of depressed
patients who experienced
lingering symptoms had
mild to moderate
physical symptoms1
*Psychiatric inpatients and outpatients.
Reference:
1. Adapted from: Paykel ES, et al. Psychol Med. 1995;25:1171-1180.
Treatments
•
•
•
•
•
•
Pharmacotherapy
Psychotherapy
Social interventions
ECT
TMS
VNS
Treatment outcome: Effect on work & social functioning
Social Adjustment Scale-SR
(Mean ± SD)
Higher Score
indicates greater
impairment
Remitted patients virtually equaled healthy controls on
functioning levels at endpoint of 12-week treatment trial
(Responders & non-responders did not)
5
3
*
**
2
*
1
Normal
(n=482)
Study in chronic depressed patients
*p.05 vs nonresponse. **p.05 vs response.
Miller IW, et al. J Clin Psychiatry. 1998;59(11):608-619.
Remission
(n=202)
Response
(n=122)
Nonresponse
(n=299)
Statistics
• 60-70% tolerant patients respond to
1st line monotherapy
• Up to 50% treated with single
antidepressant don’t reach full remission
• 1/3+ become treatment resistant
Available Types of Pharmacotherapy
But Which Medication?
• Tricyclic antidepressants
(TCA)
• MAOI’s
• SSRI’s
• SNRI’s
• Atypical antidepressants
• Mood stabilizers
• Antipsychotics
•
•
•
•
•
Safety
Tolerability
Efficacy
Payment
Simplicity
SSRIs
• Used first because of high
tolerability/ low toxicity
• No response from SSRI 1 or
2 (or intolerable)
-What’s the next step?
Med switches?
Augmentation?
Novel or Atypical
Antidepressants
• Bupropion (NE and DA
reuptake inhibition)
• Trazodone (5 HT2 alphaANT)
• Venlafaxine and Duloxetine
(NE and 5 HT reuptake
blockers – SNRI’s)
• Mirtazapine (presynaptic
alpha 2 ANT and 5 HT2 and
5 HT3 ANT)
Med Switches
• 1 in 4 patients on SSRI’s
have a response on 2nd
drug:
• Within class
1st SSRI may be ineffective/
intolerable
2nd SSRI may be effective/
tolerable
• Out-of-class
• Dual-action agent
Augmentation
• Sustained release
bupropion group
• Buspirone group
Similar response and remission
rates
BUT
Bupropion had greater
symptom reduction and
tolerability
• Quetiapine in 150 -200 mg
dose as adjuvant therapy
Many depressed patients are still
depressed.
Depressed patients continue to have needs that are not being fully addressed1
• Depressed patients present with emotional and
physical symptoms.
• Approximately 30% of depressed patients achieve
remission in clinical trials2*
• Up to 70% of patients who respond fail to remit2*
• Incomplete relief from symptoms may increase the
risk of relapse2,3
• Lingering emotional and physical symptoms may
jeopardize achieving remission.
References:
1. Nierenberg AA, et al. J Clin Psychiatry. 1999:60(suppl 22):7-11.
2. O’Reardon JR, et al. Psychiatr Ann. 1998;28:633-640.
*In antidepressant clinical drug trials.
Lynch ME.
3. J Psychiatry Neurosci. 2001;26(1):30-36.
Pseudoresistant
• Inadequate dosing/ early treatment
discontinuation
• Patient noncompliance
• Misdiagnosis
General Treatment Rules
• Often takes 4-6 weeks for response
• Monitor for response versus remission
• Vegetative symptoms tend to improve first,
cognitive symptoms take longer
• SSRI’s are the first line of treatment for most
MDD’s
• Address biopsychosocial needs and maintain
meds for 6-12 months
Psychotherapy in Depression
•
•
•
•
•
•
Supportive
Insight-oriented
Interpersonal
Cognitive-behavioral
Psychodynamic
Individual, group or family
Resources & Abilities
___ family support?
___ community support?
___ social network?
___ physical abilities?
___ functional abilities?
___ cognitive abilities?
___ financial resources?
___ personality traits? personal history?
___ experiences, beliefs, convictions?
Promote Autonomy
• Create mastery experiences
– break tasks into steps
– assure success
– promote self worth, build
confidence
• Encourage personal
control, power
– independent activity
– decision-making
– involvement in care
Focus on Positive
• Current abilities
–
–
–
–
knowledge, wisdom
experiences
attitudes, beliefs
attributes
• Reminiscence
– promotes self worth
– strengthens tie to
identify, “former self”
– stimulates interests,
conversation
Encourage Group Activities
• Psychosocial therapies
–
–
–
–
Reminiscence
Remotivation
Health, stress management
Sensory stimulation
• Many benefits
– Social interaction
– Mastery experiences
– Realization  “I am not alone in this!
Promote Creativity
• Lots of alternatives:
–
–
–
–
–
Singing, playing music
Story-telling
Drawing, painting
Poetry, writing
Making crafts, jewelry
• Associated with positive health outcomes
– Decreased depression, loneliness
– Increased health, morale, satisfaction, activity
Enhance Social Support
• Identify a “point person” to
help identify, mobilize
resources
–
–
–
–
–
–
family member
friend, neighbor
church members
clergy
volunteer visitor
peer counselor
Things to Avoid
• Don’t make long-term commitments or important
decisions unless necessary
• Don’t assume things are hopeless
• Don’t engage in “emotional reasoning” (i.e.: because
I feel awful, my life is terrible)
• Don’t assume responsibility for events which are
outside of your control
• Don’t avoid treatment as a way of coping
Bipolar Disorder
• People with this type of illness change back and forth
between periods of depression and periods of mania
(an extreme high).
• Symptoms of mania may include:
-Mood changes are usually gradual, but can be sudden
-Less need for sleep
-Overconfidence
-Racing thoughts
-Reckless behavior
-Increased energy
New Concepts of Bipolar Disorder
• Life-threatening medical illness
• Lifelong medical illness
• Lifelong treatment warranted
• Akiskal asserts at least 50% of depressions are
bipolar at some level
Potentially 8 Identifiable Patterns
• Bipolar I (Classic Pattern) - 40 – 50 % of episodes are dysphoric
Percentage of dysphoria is much higher in the psychotic condition
• Bipolar II (Sunny) - Recurrent anergic depression with hypomania often on tail end
of a
depression
•
Bipolar II ½ (Dark) - Female preponderance, Panic and social phobia often comorbid,
Suicide seems increased, Easily misidentified as Borderline PDO
• Bipolar III (Switch Sensitive Doubles) - Hypomania in response to antidepressant
therapy, Often tempermentally dysthymic and may be a “double depressive”
• Bipolar III ½ (Agitated Alcoholism) - Excitement
and minor depressions closely
linked to alcohol abuse, sometimes in abstinence, Combination treatments useful
• Bipolar IV (Executive) - Depressive episodes overlaying a hyperthymic temperament,
males with Type A personality characteristics-“narcissistic” PDO misdiagnosis
• Bipolar V (Borderline Mimic) - High recurrence rate (>5 episodes), Positive family
history, Hypomania overlays depression in a “mixed” fashion, Positive family history
• Bipolar VI (Late Onset) - Patients have early dementia, Mood instability, sexual
•
disinhibition, agitation and impulsive behavior, Antidepressants may aggravate symptoms
Remote history of hypomanic episodes or positive family history may be present (collateral
information), May be responsive to divalproate or ACD mood stabilizers,Worsen on
antidperesants, Increased importance with dementia/atypical black box
Mania and Hypomania - Questions:
• Have there been times
lasting at least a few days
when you felt the
opposite of depressed,
that is when you were
very cheerful or high and
felt different than your
normal self?
• Did you feel hyper, or like
you were high on drugs,
even though you hadn’t
taken anything?
• Did anyone notice there
was something different?
• How long did it last?
• What was your selfesteem like?
• During this time did you
sleep?
• Were you more talkative
than usual?
• Did it feel like your
thoughts were going very
fast and racing through
your mind?
• Were you easily
distracted?
• Were you more active
than usual?
Bipolar Disorder
• Lifetime prevalence1
– BP I = 1.0%-1.6%
– BP II = 0.5%
Probably underestimated
• 90% recurrence2
• Number of episodes correlates with residual symptoms
between episodes and response
to treatment2
• 25%-50% of patients attempt suicide2
– 15% suicide rate1
• High comorbidity—eg, substance abuse1
1. Evans. J Clin Psychiatry. 2000;61(suppl 13):26.
2. Brady. J Clin Psychiatry. 2000;61(suppl 13):32.
MANIA
MIXED EPISODE
HYPOMANIA
NORMAL
MOOD
DEPRESSION
5-5
Stahl S M, Essential
Psychopharmacology (2000)
Bipolar Depression
• 80% of patients exhibit
significant suicidality
• 60% of patients with
dysphoric mania exhibit
suicidality
• Depressive episodes
dominate course of
bipolar disorder (twice
the amount of time as in
mania)
• 25-30% of patients
initially diagnosed with
unipolar depression
subsequently have a
manic or hypomanic
episode
• 50% of first bipolar
episodes are depressive
episodes
• Depressive episodes in
bipolar disorder are
associated with
considerable morbidity
and mortality
• Bipolar depressive
episodes have a chronic
course
Goodwin FK and Jamison KR. Manic Depressive Illness
Impact of Bipolar Disorder Vs. Unipolar
Disorder — Heavy Impact on Daily Life
54 *
50
45
40
35
30
25
20
15
10
5
0
48 *
MDQ positive
MDQ negative
29
23
26 *
5
Ever Fired or Laid Off
* P<0.0001
Calabrese. J Clin Psychiatry. 2003;64:425-432.
Supervisor Unhappy
With Work, Behavior, or
Attitude
Jailed, Arrested, or
Convicted of a Crime
Other Than Drunk
Driving
Epidemiology
• 15% to 20% of untreated patients succeed
in committing suicide1
• High recurrence rate of bipolar disorder2
• High economic burden2
• Bipolar is a multidimensional disease1,3
1Evans
DL. J Clin Psychiatry 2000;61(suppl 13):26-31
SW. J Clin Psychiatry 2000;61(suppl 13):38-41
3Goodwin FK et al. In: Goodwin FK, Jamison KR, eds. Manic-Depressive Illness. New York, NY: Oxford University Press;1990:74-84
2Woods
Treatment Challenges in Bipolar
Disorder
Predictors of Suicide in Bipolar
Disorder
• High Impulsivity
• Alcohol and Substance
Abuse
• DEPRESSION and MIXED
Episodes
• History of Abuse in
Childhood
• Exacerbated by incorrect
treatment
•
•
•
•
•
Often unrecognized
Often untreated
Often misdiagnosed
Often inadequately treated
Exacerbated by incorrect
treatment
Akiskal. J Clin Psychopharmacol. 1996;16(suppl 1):4S-14S.
BIPOLAR DISORDER
The Major Challenge: Misdiagnosis
NDMDA survey of its bipolar members
Rate of misdiagnosis
1994
2000
73%
69%
Most frequent misdiagnosis: Unipolar depression
Treatment as unipolar depression can lead to
worsening of symptoms by switching into mania or cycle
acceleration
Goodwin & Jamison (1990); Hirschfeld et al (2003); Lish et al (1994)
Physician Diagnoses Among MDQ
Positives in the Community
Dx with
bipolar disorder
20%
Neither bipolar
disorder nor
depression Dx
49%
31%
Dx with depression
but not bipolar disorder
80% of patients who screened positive
for BP were not diagnosed w/ BP
Hirschfeld RMA, et al. J Clin Psychiatry. 2003;64:53-59.
Steps to Increase Recognition of Bipolar
Disorder and to Improve Diagnosis
• Education of physicians about the illness, particularly how it
presents itself in clinics
• Ask patients directly about history of symptoms of Bipolar
Disorder
• Involve family members in clinical evaluations
• Increase patients’ and families’ awareness of the illness
• Screen for Bipolar Disorder, especially in depressed patients
The Evolution of Therapies
for Acute Mania/Hypomania
1940
ECT
*Approved
1950
1960
1970
1980
1990
2000
2002
Lithium*
First-generation
antipsychotics
Second-generation
antipsychotics
Chlorpromazine*
Trifluoperazine*
Fluphenazine
Thioridazine
Haloperidol
Mesoridazine
Clozapine
Risperidone
Olanzapine*
Quetiapine
Ziprasidone
Anticonvulsants
Anticonvulsants
Carbamazepine
Valproate*
Gabapentin
Lamotrigine
Topiramate
Oxcarbazepine
for use for acute mania.
McElroy and Keck. Biol Psychiatry. 2000;48:539.
Nemeroff. J Clin Psychiatry. 2000;61(suppl 13):19.
Next-generation
antipsychotics
Aripiprazole
Why are SOME Anticonvulsants
Mood Stabilizers?
Valproate, Carbamazepine,
Oxazapine, Lamotrigine, Clonazepam
• Reducing glutamate and
increasing GABA
transmission potentially
– Raises the seizure
threshold
– Reduces overstimulation
– Prevents or inhibits
behavioral sensitization
– Prevents or inhibits
kindling
• Yet not all anticonvulsants
are mood stabilizers
Other ANTICONVULSANTS
•
•
•
•
•
Gabapentin
Pregabalin
Levetiracetam
Tiagabine
Topiramate
NO PROVEN
EFFICACY
Treatments with Evidence for
Effective Continuation
Try to use treatments with evidence for relapse
prevention in patients who have responded to
the drug:
– Lithium
– Divalproex
– Atypicals: olanzapine has best evidence
– Combination of lithium or divalproex with
olanzapine or risperidone
Valproate / Divalproex
• Uses
– acute mania and maintenance treatment of bipolar
disorder
– ? bipolar depression
• Advantages
– better tolerability than lithium
– can be loaded rapidly
– once-a-day formulation available
• Disadvantages
– drug-drug interactions
– fetal abnormalities
Appropriate Use of Monotherapy
• 30 - 40% of patients succeed on monotherapy
• Complex regimens
–Are expensive
–May decrease adherence
–Pose difficulty in elucidating which medications
are beneficial and which cause side effects
Bowden CL, et al. JAMA. 1994;271:918-924.
When Monotherapy Is Not Enough
• Many patients remain symptomatic on
monotherapy
• After patients are treated with the right dose for
an adequate time period, assess symptom
response
• Combination therapy may be required
– Acute psychosis, bipolar mania, and bipolar depression
– Maintenance treatment for full symptom remission
Choosing Treatment
• Episode characteristics
– Pure, uncomplicated mania: favorable response to all
treatments
– Predictors of poor lithium response:
• Severity; psychosis
• Mixed/depressive features
• Complications
• Past history
– Unstable course of illness
– History of complications (e.g., head trauma, substance
abuse) predisposes to mixed states
Selection of Treatments
• Start with proven treatments
• Use response predictors
• Identify and monitor target symptoms
• Assure adequate dose and time
• Additional/new treatments based on evidence
and feasibility
• Collaborate
Finding the Best Dose
• Establish diagnostic context and target symptoms
• Priorities: is time of the essence?
• Increase dose to maximum that is tolerated
• Evaluate response and toleration
– Not improving: tolerating or not?
– Improving: if levels feasible, steady-state level as
benchmark
• Primary consideration is how the patient
responds, not dose or level
If Patient Response is Inadequate
• Tolerating: increase dose
• Not tolerating or extenuating circumstances
– Augment
– Reduce dose and augment
– Switch to another treatment
• Augmentation
– Drug with complementary mechanism
– Pharmacokinetically compatible
– A drug that you are comfortable giving the patient for at
least six months, or preferably indefinitely
Lamotrigine in Acute Treatment of Bipolar Depression
Change From Baseline of MADRS
LTG 50 mg/day (n = 64)
LTG 200 mg/day (n = 63)
LOCF
Observed
0
0
-5
-5
-10
Placebo (n = 65)
*
†
*
†
-15
-10
†
†
†
†
-20
-15
†
†
†
†
†
†
3 4 5
Week
6
†
-20
0
1
2
3 4 5
Week
6
7
0
1
2
* P<0.1; † P<0.05. LOCF = last-observation-carried-forward.
Calabrese et al. J Clin Psychiatry. 1999;60:79-88.
7
Strategy and Time Course
Acute
0 - 8 weeks
Continuation
1 - 6 months
Maintenance
Indefinite
Functional recovery
Maximized function;
stability
Maximize moodOptimize tolerability;
stabilizers; adjunctive taper adjunctive
treatments
when possible
Optimize; anticipate
prodromes
Syndromal recovery
Support/structure;
education; involve
family
Behavioral; systems; Strategies to
institute monitoring
optimize adaptation
Sachs et al. J Clin Psychopharm 1996. 16(2suppl1):32s-47s; Tohen et al. Am J Psychiatry 2000. 157:220-228.
Anticipating an Episode
• Prodromes weeks-months before episodes
consistent within individuals
– Smith & Tarrier. 1992. Soc Psychiat Psychiat Epid 27:245-248.
• Look for early changes in the underlying illness
– Motivated activity
– Sleep-activity cycle
– Impulsivity
– Interpersonal behavior
– Affect – often is a later indicator
Consequences Of Premature Treatment
Discontinuation
Probability of
Remaining in
Remission (%)
100
Lithium or valproate + olanzapine (n = 30);
Li = 0.78, VPA = 69.2
Lithium or valproate monotherapy (n = 38);
Li = 0.75, VPA = 67.6
80
60
*
40
*P = 0.023
Early relapse when part of
treatment was withdrawn
20
0
0
100
200
300
400
500
Time to Recurrence of Mania or Depression
(days)
Subjects had reached remission on combination treatment and
were randomized to have olanzapine withdrawn or continued
Tohen ME, et al. Br J Psychiatry, 2004.
Long-term Antidepressants in Bipolar
Disorder
• No evidence for relapse prevention in controlled
studies
– Ghaemi
• Patients who required antidepressants for an acute
episode (15-20% of patients) appeared to benefit from
6-12 months continuation
– Altshuler L et al. Am J Psychiatry 2003(July):160(7):1252-1262.
• Pattern of poor response/loss of response
– Sharma et al. J Affect Disord 2005:84:251-257.
• Development of irritable dysphoria during long-term
treatment
– El-Mallakh & Karippot. J Affect Disord 2005:84:267-272.
Combinations
• Lithium plus valproate
• Atypical plus lithium/valproate
–
–
–
–
Risperidone
Olanzapine
Quetiapine
Combination therapy appeared more efficacious, but
doses of mood stabilizer were often inadequate
• Antipsychotic plus valproate
– Valproate addition reduced antipsychotic dose and
improved outcome
Valproate Reduces Neuroleptic
Requirement in Mania
120
Neuroleptic % Dose
100
80
60
40
Placebo
Valproate
20
0
0
5
10
15
20
Day
Muller-Oerlinghausen et al. J Clin Psychopharmacology 2000;20:195-203.
25
Summary of Combination Therapy for
Acute Mania in Bipolar Disorder
• Combination therapy is efficacious in treatment of acute
mania in bipolar disorder
– Divalproex and lithium
– Divalproex or lithium and atypical antipsychotics (risperidone, olanzapine,
quetiapine)
– Divalproex or lithium and typical antipsychotics (haloperidol)
• Combination therapy randomized, controlled studies that
included lithium and/or divalproex used suboptimal doses,
yet demonstrated increased efficaciousness with these
agents
• Combination therapy with divalproex could result in lower
doses of antipsychotic agent
• Divalproex and lithium are the foundation of bipolar therapy
Switch Rates on Antidepressants
• All antidepressants while on mood stabilizers
• High rates of switch (over 10% short term)
– TCA’s, venlafaxine, MAOI’s
• Low rates of switch (under 10% short term)
– Bupropion, SSRIs
• Much higher if not on a mood stabilized
• Paroxetine is the most well studied: three double
blind studies
• All add-on
• All double blind against placebo, imipramine,
venlafaxine, and combined lithium and divalproex
Young et al., Am J Psychiatry 2002; Nemeroff et al., Am J Psychiatry
2001; Vieta et al., J Clin Psychiatry 2002
ON THE OTHER HAND
Depression Following Antidepressant Discontinuation in Bipolar Patients
(Chart Review)
100%
% Well ( Not Depressed)
90%
Continued
Antidepressant n=19
80%
70%
60%
50%
40%
30%
Discontinued
Antidepressant n=25
20%
10%
0%
0
13
26
Weeks After Improvement
Altshuler et al., J Clin Psychiatry, 2001; 62:612-616.
39
52
Psychosis Is Common in Bipolar
Disorder
• Two-thirds of patients have at least 1
psychotic symptom.
• All forms of psychosis, including moodincongruent, bizarre, Schneiderian firstrank symptoms, formal thought disorder,
and catatonia may occur in Bipolar I
disorder.
Goodwin FK, Jamison KR. Manic-Depressive Illness. New York, Oxford University Press, 1990;
Tohen M, et al. Am J Psychiatry 1992.
Strategies for Reducing Suicidal Risk
• Prevent episodes, especially depressive, mixed (Swann 2000)
• Reduce impulsivity and substance abuse (Corruble 1999)
• Lithium more effective than carbamazepine in treating classical
bipolar cases (Greil 1998)
• Lithium, divalproex equally effective in pure manic patients;
divalproex more effective than lithium in patients with mixed mania
or psychotic symptoms in only controlled study (Bowden 1998)
• Provide structured, supportive therapeutic relationship (Vestergaard
1991)
Swann AC. 2000; Corruble E, et al. J Affect Disord 1999; Greil W, et al. J Clin Psychopharmacol 1998;
Bowden CL. Neuropsychopharmacology 1998; Vestergaard P, Aagaard J. J Affect Disord 1991.
APA Practice Guidelines for the Treatment of
Patients With Bipolar Disorder
Maintenance Treatment
• Medication with the best
evidence for maintenance
– Lithium and valproate
– Alternatives include lamotrigine or
carbamazepine or oxcarbazepine
– Maintenance ECT may also be
considered
• Antipsychotics should be
discontinued unless required for
persistent psychosis or
prophylaxis against recurrence
• While maintenance with atypical
antipsychotics may be
considered, no definitive
evidence comparable to lithium
or valproate
• Likely benefit from concomitant
psychosocial intervention
– Psychotherapy to address illness
management (adherence, lifestyle
changes, early detection of
prodromal symptoms) and
interpersonal difficulties
• Group therapy may also address
adherence, adaptation, selfesteem, and personal and
psychosocial issues
• Support groups provide useful
information about bipolar
disorder and its treatment
American Psychiatric Association. Am J Psychiatry. 2002;159(Suppl 4):1-50.
Summary
• Maximize standard mood stabilizers, including
combination.
• Utilize anxiolytic/hypnotics, atypical
neuroleptics, and novel anticonvulsants as
mood stabilizers to adjunctive therapy.
• Brief, acute intermittent antidepressant
treatment.
• Address psychoeducational needs.
The “Big 5” Personality Traits





Openness to experience
(v. premature closures)
Conscientiousness
(v. irresponsibility)
Extraversion
(v. introversion)
Agreeableness
(v. uncooperativeness)
Neuroticism
(v. a healthy world view and positive adjustments)
 personality disorders represent extreme variations
of OCEAN
Main Features of PDs
• Extreme patterns of thinking, feeling, and behaving that
deviate from a person’s culture
• Listed on Axis II of the DSM-IV-TR
• Begin early in life and remain stable
• Not contextual or transient, Little behavior change over
time
• Inflexible and maladaptive, Effects behavior in many
situations
• Cause significant functional impairment and subjective
distress
• Ego-syntonic vs. ego-dystonic
• Causes distress in others due to dysfunctional theory of
mind
• Onset usually late childhood, early adolescence
• Pathological uncooperativeness, Poor insight
Personality Disorders require 3
overarching characteristics:
What are they?
Personality Disorder
- Inflexible patterns of behavior (maladaptive)
- Begins early in adulthood (lifelong)
- Results in social, occupational problems or
distress (pervasive)
Cluster A
Cluster B
Cluster C
Odd, Eccentric
Angry
Anxious
Cluster A Personality Disorders
Paranoid, schizoid, and schizotypal personality
disorders
Marked by eccentricity, odd behavior, not
psychosis
Share a superficial similarity with schizophrenia
(as if a milder version)
Cluster C Personality Disorders
Avoidant, obsessive-compulsive, dependent
disorders
Individuals are often anxious, fearful, and
depressed
Cluster B Personality Disorders
Antisocial, borderline, histrionic, and
narcissistic personality disorders
Being self-absorbed, prone to
exaggerate importance of events
Having difficulty maintaining close
relationships
Poor capacity to engage in ongoing
cooperative relationships
Primary Cluster B
Personality Disorders
John Gunderson, MD
•
•
•
•
•
Borderline
NOS
22%
Narcissistic
Antisocial 7%
Histrionic 1%
56%
14%
•
•
•
•
Psychotic Borderline
The Borderline Syndrome
The As – If Borderline
The Neurotic Borderline
“Borderline Personality
Organization” - Kernberg
Grinker, Werble and Drye, 1968
BORDERLINE PD
Unstable Relationships, Affect Disturbance,
Dysfunctional Self-Image Plus Impulsiveness
AND 5 + of :
• Fears Abandonment
• Mood Shifts (Affective
Instability, hours, even
minutes)
• Unstable Relationships
Feels Empty
• Changing Self-Image
• Impulsive Sex, Spending
• Identity disturbances
• Recurrent suicidal or
self-mutilating
behavior
• Feelings of emptiness
• Inappropriate intense
anger
• Transient paranoia or
dissociation
• Paranoia
Borderline and comorbidity
• High degree of overlap with both Axis I and
Axis II disorders
• 24%-74% also diagnosed with major
depression; 4% to 20% bipolar
• 25% of bulimics also diagnosed with BPD
• 67% also diagnosed with substance use
disorder
Splitting
A primitive defense. Negative and positive
impulses are split off and unintegrated.
Fundamental example: An individual views
other people as either innately good or
innately evil, rather than as a whole
continuous person.
* Tellin’ a man to go to hell and makin’ him do it
are two entirely different propositions
Acting Out
Acting Out is performing an extreme behavior in
order to express thoughts or feelings the person
feels incapable of otherwise expressing. Instead
of saying, “I’m angry with you,” a person who acts
out may instead throw a book at the person, or
punch a hole through a wall. When a person acts
out, it can act as a pressure release, and often
helps the individual feel calmer and peaceful
once again. For instance, a child’s temper
tantrum is a form of acting out when he or she
doesn’t get his or her way with a parent. Selfinjury may also be a form of acting-out,
expressing in physical pain what one cannot stand
to feel emotionally.
Projective Identification
Projective Identification refers to a psychological process in
which a person engages in the ego defense mechanism
projection in such a way that their behavior towards the
object of projection invokes in that person precisely the
thoughts, feelings or behaviors projected.
Projective identification differs from simple projection in that
projective identification is a self-fulfilling prophecy,
whereby a person, believing something false about
another, relates to that other person in such a way that the
other person alters their behavior to make the belief true.
The second person is influenced by the projection and
begins to behave as though he or she is in fact actually
characterized by the projected thoughts or beliefs. This is a
process that generally happens outside the awareness of
both parties involved, though this has been debated.
So…When you give a lesson in meanness to a critter or a
person, don’t be surprised if they learn their lesson.
Reducing Suicide Risk
• Use medicines that reduce recurrence and impulsivity
• Work for early recognition of risky internal states and
of early signs of recurrence
• Dialectical Behavior Therapy
• Foster a forward-looking approach
–
–
–
–
–
–
Social structure and contact
Sequential, attainable goals
Constructive anticipation of changes and problems
Responsibility for health and decisions
Encourage mindfulness of behavior
Construct and observe careful and appropriate boundaries
TRUE
FALSE
Suicide in Older Adults
• Represent 13% of the
population
• Account for 1/5 (20%) of
all reported suicides
• Lowest rate of ATTEMPTS
• Highest rate of COMPLETED SUICIDE
Indirect Suicide
• Starvation, refusing
to eat
• Refusing needed
medications
• Mixing medications
• Alcohol abuse
• Loss of “will to live”
Poor Outcomes
Comorbid Conditions
• Anxiety
• Medical problems
• Cognitive impairment
Concurrent Problems & Issues
• Psychotic depression
• Impaired social support
• Stressful life events
• Multiple previous episodes
Incidence of Post Stroke Depression
• Approximately 1/3 of persons will experience
clinically significant depression at some point
following a stroke. Hacket, et al., 2005
• Robinson found that 19.3% and 18.5% of stroke
survivors had major depression or minor depression,
respectively, in acute care rehabilitation settings.
Robinson, RB, 2003
• No significant difference in incidence between
hemorrhagic and infarct strokes
Distinguishing types of crying:
• Pathological crying linked to infarct in basis of pontis
and corticobulbar pathways and occurs in response
to mood incongruent cues.
• Emotionalism is crying that is congruent with mood
(sadness) but patient is unable to control crying as
they would have before stroke.
• Catastrophic reaction is crying or withdrawal
reaction triggered by a task made difficult or
impossible by a neurologic deficit (e.g. moving a
hemiplegic arm)
LONG TERM CONSEQUENCES OF
POSTPARTUM MAJOR DEPRESSION
• Babies of mothers with
PMD were perceived
by their mothers as
more difficult to care
for and more
bothersome.
Postpartum Blues
• Often viewed as “normal”
• Affects 40 to 85% of new
mothers
• Peaks between
postpartum days 3 and 5
• Resolves within 24 to 72
hours
• Subsides without
treatment by postpartum
day 14
• Symptoms:
– Sadness, anxiety, irritability
– Uncontrollable tearfulness
– Wide mood swings
– Occasional negative
thoughts
• Primary Treatment:
– Supportive care and
reassurance about the
condition
Postpartum Depression
• Difficulty concentrating
or making decisions
• Psychomotor agitation
or retardation
• Feelings of
worthlessness or guilt
(especially focusing on
failure at motherhood)
• Fatigue
• Excessive anxiety
• Changes in appetite
and/or sleep patterns
• Frequently focusing on
the child’s health
• Recurrent thoughts of
death or suicide
Postpartum Psychosis
Rare condition, affecting 1 to 2 out of
1000 women after childbirth
Onset as early as 48 to 72 hours
postpartum
Presentation can be dramatic
Symptoms develop within the first 2
weeks after delivery
• Early Symptoms
– Restlessness
– Irritability
– Sleep disturbance
• Progressive Symptoms
– Depressed or elated
mood
– Disorganized behavior
– Mood swings/
instability
– Delusions
– Hallucinations
Suicide Assessment
Always ASK!!!
“Have you thought that life isn’t worth living?”
If YES, then . . .
“Have you thought about harming yourself?
If YES, then . . .
“Do you have a plan?”
If YES, examine lethality. . .
Is the plan viable? Can they execute it?
Are means deadly, available?
References
• Blais MA, Smallwood P, Groves JE, Rivas-Vazquez RA.
Personality and personality disorders. In: Stern TA,
Rosenbaum JF, Fava M, Biederman J, Rauch SL, eds.
Massachusetts General Hospital Comprehensive Clinical
Psychiatry. 1st ed. Philadelphia, Pa: Mosby
Elsevier;2008:chap 39.
• Borderline Personality Disorder Demystified by Robert
O. Friedel, M.D., Marlowe & Co., 2004
• National Education Alliance for Borderline Personality
Disorder’s Teachers Manual for Family Connections,
2006
• A BPD Brief, An Introduction to Borderline Personality
Disorder by John G. Gunderson, M.D., 2006
• A REMINDER for assessing psychosis- John Hendrick,
MD- CURRENT PSYCHIATRY April 2010 Volume 9, No. 4