Bipolar

Depressive
Episode
Definition
 Bipolar disorder is a brain disorder that
cause unusual shift in mood, energy,
activity level and ability to carry out day
to day task and expresses itself in an
irregular pattern of change in mood
Etiology
1. Genetic factor
About half the people with bipolar disorder
have a family member with a mood
disorder, such as depression. A person who
has one parent with bipolar disorder has a
15 to 25 percent chance of having the
condition.
2. Neurochemical factors
Brain chemicals  norepinefrin, serotonin, dopamine
Norepinefrin and serotonin have been consistently
linked to psychiatric mood disorder such as depression
and bipolar depression and serotonin is connected to
many body function, sleep wakefulness, eating, sexual
activity, learning and memory.

Biochemical imbalance, abnormal serotonin chemistry

 irregular hormone production or certain
neurotransmitter  stress hormone

Depression  left-sided lesion brain

3. Environmental factor
Alcohol, drug abuse, hormonal problems 
increase the risk
Sign and
Symptoms
Bipolar
Affective
Disorder
 Bipolar affective disorder is characterized
by periods of deep, prolonged, and
profound depression that alternate with
periods of an excessively elevated or
irritable mood known as mania.
Manic episode
 Manic episodes are feature at least 1 week of
profound mood disturbance, characterized by
elation, irritability, or expansiveness (referred to as
gateway criteria). At least 3 of the following
symptoms must also be present :
 Grandiosity
 Diminished need for sleep
 Excessive talking or pressured speech
 Racing thoughts or flight of ideas
 Clear evidence of distractibility
 Increased level of goal-focused activity at home, at
work, or sexually
 Excessive pleasurable activities, often with painful
consequences
Hypomanic episodes
 Hypomanic episodes are characterized by an
elevated, expansive, or irritable mood of at least 4
consecutive days’ duration. At least 3 of the
following symptoms are also present[2] :
 Grandiosity or inflated self-esteem
 Diminished need for sleep
 Pressured speech
 Racing thoughts or flight of ideas
 Clear evidence of distractibility
 Increased level of goal-focused activity at home, at
work, or sexually
 Engaging in activities with a high potential for painful
consequences
Depressive episodes
 Major depressive episodes are characterized as, for the same 2
weeks, the person experiences 5 or more of the following
symptoms, with at least 1 of the symptoms being either a depressed
mood or characterized by a loss of pleasure or interest[2] :
 Depressed mood
 Markedly diminished pleasure or interest in nearly all activities
 Significant weight loss or gain or significant loss or increase in
appetite
 Hypersomnia or insomnia
 Psychomotor retardation or agitation
 Loss of energy or fatigue
 Feelings of worthlessness or excessive guilt
 Decreased concentration ability or marked indecisiveness
 Preoccupation with death or suicide; patient has a plan or has
attempted suicide
Physical
Examination
Appearance (Depressed Phase)
 No eye contact
 unkempt, unclean, holed, unironed, and
ill-fitting
 move slowly and very little
 Fingernails
 they may talk in low tones or in a
depressed or monotone voice
Mood / Affect
 Helpless/ Hopeless
 sad, depressed, lost, vacant, and isolated
 sadness dominates the affect
Thought Content
 Patients experiencing a depressed
episode have thoughts that reflect their
sadness. They are preoccupied with
negative ideas and nihilistic concerns,
and they tend to "see the glass as half
empty." They are likely to focus on death
and morbid persons, and many think
about suicide.
Perceptions
 Two forms of a major depression are described,
one with psychotic features and the other without.
With psychosis, the patient experiences delusions
and hallucinations that are either consistent or
inconsistent with the mood. The patient’s delusions
of having sinned are accompanied by guilt and
remorse, or the patient feels he or she is utterly
worthless and should live in total deprivation and
degradation. Hence, the delusional content
remains consistent with the depressed mood.
Some patients experience delusions that are
inconsistent with the depression, such as paranoia
or persecutory delusions.
Suicide / Self destruction
 Patients experiencing a depressed episode have a very high rate of
suicide. They are the individuals who attempt and succeed at killing
themselves. Query patients to determine if they have any thoughts of
hurting themselves (suicidal ideation) and any plans to do so. The more
specific the plan, the higher the danger.
 Dubovsky has reported that the highest lifetime suicide risk (17.08%) is in
men with bipolar disorder and deliberate self-harm.[67] Similarly, in a
European study of adults with bipolar disorder, Bellivier and colleagues
found that 29.9% had a history of at least 1 attempt of suicide (663 of
2219 patients who provided data on lifetime history of suicide
attempts).[68] However, female sex, history of alcohol abuse, history of
substance abuse, young age at first treatment for a mood episode,
longer disease duration, greater depressive symptom severity (5-item
Hamilton Depression Rating Scale [HAMD-5] total score), current
benzodiazepine use, higher overall symptom severity (Clinical Global
Impression-Bipolar Disorder [CGI-BP] scale: mania and overall score), and
poor compliance were the baseline factors associated with a history of
suicidal behavior.[68]
 As patients emerge from a period of depression, their suicide risk may
increase. This may be because, as the illness remits, executive functions
are improved to the point where the person is again capable of making
and carrying out a plan while the subjective feeling of depression and
accompanying suicidal thoughts persist.
Homicide/violence/aggression
 In patients experiencing a depressed episode, suicide
generally remains the paramount issue. However, certain
persons in the depths of a depression see the world as
hopeless and helpless not only for themselves but also for
others. Frequently, that perspective can create and lead to
a homicide followed by a suicide.
 For example, a 42-year-old mother of 2 was experiencing a
significant depression as part of her bipolar disorder. She
believed the earth was doomed and was a terrible place
to dwell. Furthermore, she thought that if she died, her
children would be left in a wretched place. Because of this
view, she planned to kill her 2 children and then herself.
Fortunately, her family recognized the state of affairs, which
led to an emergency intervention and her hospitalization.
Insight
 In persons experiencing a depressive episode, the
depression clouds and dims their judgment and
colors their insights. They fail to make important
plans/actions, because they are so down and
preoccupied with their own plight. These
individuals see no tomorrow; therefore, planning
for it is difficult. Frequently, persons in the middle of
a depression have done things such as forgetting
to pay their income taxes. At that time, they have
little insight into their behavior. Often, others have
to persuade them to seek therapy because of
their lack of insight.
Cognition
 Impairments in orientation and memory are
seldom observed in patients with bipolar disorder
unless they are very psychotic. They know the time
and their location, and they recognize people.
They can remember immediate, recent, and
distant events. In some cases of hypomanic and
even manic episodes, their ability to recall
information can be extremely vivid and
expanded. However, later in the course of their
illness, their cognition becomes impaired. In
extremes of depression and mania, these
individuals may experience difficulty in
concentrating and focusing. Similar to subcortical
dementia, depression impairs cognition.
Physical Health
 Although the MSE has been used in this article
to highlight key aspects of the examination,
the clinician must pay particular attention to
the patient’s physical health. As Fagiolini
pointed out, patients with bipolar disorder
have a high incidence of endocrine disorders,
cardiovascular disorders, and obesity,[70] and
these factors must be considered when
medications are prescribed.[70, 71]
DD
 Monopolar Affective Disorder (depression)
 Skizofrenia Simpleks
Management
of Bipolar
Disorder
 A complete clinical assessment should be
obtained for patients with BD depression
episode to include:
a. Clinical status
b. Medical comorbidities
c. Psychiatric comorbidities
d. Psychosocial status
e. Current medications
f. Past medications
g. Medication compliance
h. Substance use
Refer for Hospitalization
The usual reasons for urgent hospitalization include
acute suicide risk; acute violence risk due to mental
illness; delirium, and acute unstable medical
condition. Specialized treatments only available or
often best provided in an inpatient settinginclude:
 Electro-convulsive therapy (ECT)
 Close monitoring and daily titration of medications with
disabling side effects or toxicity
 Constant staff observation as part of an intensive
behavioral modification program
 Close monitoring of behavior in an episodic disorder
 Close monitoring of vital signs or need for multiple daily
laboratory or electrophysiological testing.
Pharmacotherapy for Bipolar
Depression
General considerations
1. Pharmacotherapy for bipolar depression should start with initiation or
optimizationof a medication that has been shown to be the most effective in
treating bipolar depressive episodes, while minimizing the potential risks. (see
Table )
2. Consider using the agent(s) that have been effective in treating prior episodes of
depression.
3. The risk for mood destabilization or switching to mania should be evaluated and
the patient should be monitored closely for emergent symptoms after initiation of
pharmacotherapy for a depressive episode.
4. For patients with BD depression with psychotic features, an antipsychotic
medication should be started.
5. Consider adding one of the evidence based psychotherapeutic interventions to
improve adherence and patient outcome.
6. In selectinga drug treatment regimen for patients with bipolardisorder, clinicians
should be aware of the patient’s other psychiatric and medicalconditions
andshould try to avoid exacerbating them.
7. In selectinga drug treatment regimen for patients with diabetes or obesity
consider the risk and benefit ofutilizing medications that are lessassociated
withweight gain.
Effectiveness of Medication in Acute
BipolarDepression
 Monotherapy
1. Quetiapine, lamotrigine , or lithium monotherapy should be
considered as first-linetreatment for adult patients with BD
depression.
2. Olanzapine/fluoxetine combination (OFC) should be considered
for treatment of BD depression, but itsadverse effects (weight
gain, risk of diabetes, hypertriglyceridemia) places this
combination as a second-line treatment.
3. Olanzapine alone may be considered for BD depression, but
adverse effects require caution.
4. There is insufficient evidence to recommend for or against the use
of valproate, carbamazepine, topiramate, risperidone,
ziprasidone, or clozapine for BD depression.
5. Aripiprazole NOT recommended for monotherapy in the
treatment of acute bipolar depression, unless there isa history of
previous good response during depression without switch to
mania or a history of treatment refractory depression.
 Combination Strategies
1. Combining lithium with lamotrigine can be considered for patients with BD
depression who do not respond to monotherapy.
2. When patients do not respond to treatment options that have shown better
efficacy, antidepressant augmentation with SSRI, SNRI, buproprion, and
MAOIcanbe considered for short-term treatmentmonitoring closely for
triggering of manic symptoms
3. Clozapine may be considered for augmentation, usingcaution regarding
metabolic or other adverse effects.
4. There is insufficient evidence to recommend for or against use
ofaugmentationwitharipiprazole,olanzapine, risperidone,haloperidol,
oxcarbazepine, topiramate, ziprasidone, valproate, or carbamazepine for
the treatment of bipolar depression.
5. Gabapentin and the tricyclic antidepressants(TCAs) areNOT recommended
for monotherapy or augmentation in the treatment of acutebipolar
depression, unless there is a history of previous good response during
depression without switch to mania or a history of treatment refractory
depression.
Institute Maintenance Medicationsthat
Have Demonstrated Clinical Efficacy
for At Least 6 Months.
 Patients with bipolar disorder whose acute
symptoms of a manic or depressive episode
have been in remission for three to six months
should begin long-term maintenance on
prophylactic treatment and psychosocial
rehabilitation.
 Pharmacotherapy should optimally consist of
a clinically effective medication for the
prevention of manic and depressive episodes
and should be prescribed to patients with
bipolar disorder in the maintenance phase.
Asess for Adverse Event within 2
weeks
Assess for adverse effects and tolerability after
any change of treatment strategy
1.Using a standardized clinical tool in addition
to a clinical interview, assess for response to
treatment, adherence to treatment and
adverse effects of treatment after initiating or
changing treatment.
2.Identifiedside effects should be managed to
minimize or alleviate if possible.
 Recommended Pharmacotherapy Monitoring:Lithium, Antiepileptics
 Monitoring
Parameter
s and
Frequency
for
Metabolic
Adverse
Effects
Secondary
to Second
Generatio
Antipsych
otics
 Monitoring
Paramete
s and
Frequency
for
Metabolic
Adverse
Effects
Secondar
y to
Second
Generatio
n
Antipsych
otics
Modify Dose or Medication if Indicated, Using
Medications Effective for Bipolar Depression
1. If patient is having intolerable side effects switch to another effective treatment
2. If the patient has switched into mania or hypomania or entered a mixed manic state, go
to Module A (Acute Mania) [I]
3. Assess compliance and blood serum concentration to assess if medications are in
therapeutic range [I]
1. The serum trough concentrationof lithium should be maintained between 0.8 - 1.2 mEq/L
2. The serum trough concentrationof valproateshould be maintained between 50-125 mcg/ml
3. The serum trough concentrationof carbamazepine should be maintained between 4 – 12
mcg/ml.
4. If medication is not in therapeutic range, adjust medication to maximum range
5. Medications without known therapeutic plasma concentrations should be increased
untilsignificant improvement is seen, side effects become intolerable or the dose reaches
the manufacturer’s suggested upper limits.
6. 6.Adjust medications if there is no response within 2 – 4 weeks on an adequate dose of
medication. Adjustment may include:
1. Augmenting with additional agents
2. Discontinue the current agent and switch to another effective medication
3. If multiple trials of switching medications or augmentation strategies have not been
effective consider ECT
7. 7.Any discontinuation of medication used to treat bipolar depression should be tapered
and the patient should be monitored for antidepressant discontinuation syndrome and
mood destabilization.
8. 8.Risks and benefits of long term pharmacotherapy should be discussed prior to starting
medication and should be a continuingdiscussion item during treatment.
 Ongoing assessment of patients starting treatment for acute
bipolar depression should include a reassessment for:

1. Changes in depressive symptoms

2. Neurovegetative symptoms
3. Emerging symptoms of mania/hypomania
4. Psychotic symptoms
5. Development of suicidal or homicidal ideation
6. Substance use
7. Adverse effects of medications
8. Medication compliance
9. Medical stability (e.g., blood pressure)
10. Significant changes in psychosocial circumstan
 Reassess patient every 1 to 2 weeks for at
least 6 weeks.
 Ongoing assessment of patients starting
treatment for acute bipolar depression
May Include pertinent laboratory studies
(e.g., medication plasma concentrations,
urine drug screening, CBC, blood glucose,
liver panel, lipid panel) and weight.
PSYCHOEDUCATION
1.Patient should receive psychoeducation that emphasizes:
a. The importance of active involvement in their treatment
b. The nature and course of their bipolar illness
c. The potential benefit and adverse effects o
d. treatment options
e. The recognition of early signs of relapse
f. Behavioral interventions that canlessen the likelihood of
relapse including careful attention to sleep regulation and
avoidance of substance misuse.
2.With the patient’spermission, family members or significant
othershould be involved in the psychoeducation process.
3.A structured group format in providing psychoeducation
and care management for patients with clinically
significant mood symptoms should be considered.
PSYCHOTHERAPY STRATEGIES
COGNITIVE BEHAVIORAL (CBT)
 Implementation of CBT should include components of:
a. Education regarding symptoms, course and treatment of BD,
b. Scheduling of pleasurable events to alleviate inactivity,
c. Teaching the skill of cognitive re-structuring,
d. Learning to identify maladaptive thoughts and challenge
them on logical grounds,
e. Learning to replace maladaptive thoughts with balanced or
adaptive thinking,
f. Problem solving, and
g. Learning to detect the earliest signs of recurrence and
implement early intervention plans.
PSYCHOTHERAPY STRATEGIES
INTERPERSONAL AND SOCIAL RHYTHM THERAPY (IPSRT)
 Interpersonal and Social Rhythm Therapy (IPSRT) should
contain the following components:
a. Patients should complete the Social Rhythm Metric questionnaire
which is a self-report instrument for tracking and quantifying daily
and nightly routines, alongwith ratings of mood
b. Providers need to assist patients in keeping regular routines (e.g.,
bed times, wake times, exercise) and minimizing the impact of
events that could disrupt their moods and daily/nightly stability
c. Providers need to maintain an interpersonal focus that concerns
the resolution of the patient’s current problems (e.g., how to
communicate better with one’s spouse) and developing
strategies for preventing the same problems from recurring in the
future.
PSYCHOTHERAPY STRATEGIES
FAMILY THERAPY
 Family focused therapy should contain the following
four components:
a. Initial assessment,
b. Psychoeducation about the nature, course, and
treatment of BD, including the importance of
medication consistency, identifying early warning
signs of relapse, and implementing relapse prevention
strategies,
c. Communication and enhancement skills, notably role
playing and rehearsal of tools for active listening and
expressing positive or negative feelings, and,
d. Problem solving skills