Dubovsky-WED-GSFL20.pdf - Bipolar Disorder Comprehensive...

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2/3/2020 1 Bipolar Disorder: Comprehensive Update Steven L Dubovsky, M.D. Psychosis Manic Depressive Insanity Dementia Praecox Remission / recurrence Deterioration
2/3/2020 2 It is becoming increasingly clear that we cannot distinguish satisfactorily between these two illnesses [manic depressive insanity and dementia praecox], and this brings home the suspicion that our formulation of the problem may be incorrect. Kraepelin, 1920 Secular Changes in Epidemiology of Mood Disorders in 20th Century Increasing incidence (new cases) Younger age of onset Increasing severity and complexity More violent bipolar adolescents
2/3/2020 3 Why is the Prevalence of Mood Disorders Increasing? Assortive mating Accumulation of genetic risk Anticipation Accumulation of trinucleotide repeats Decreased modulation of arousal by families Increased exposure to overstimulation in media Increased treatment of younger patients with antidepressants and stimulants
2/3/2020 4 Spectrum of Mania Hyperthymia Elevated activity Reduced sleep Optimistic Cyclothymia Mild mood swings Hypomania Symptoms last days No impaired functioning or psychosis No hospitalization Mania Psychosis Gross impairment Categorical Bipolar Spectrum Hypomania Bipolar II Mania Bipolar I Hypomanic symptoms lasting < 4 days Brief hypomania Elation/irritability or hyperactivity + 3 symptoms Bipolar specifier Hypomania without Impairment; elation/ Irritability + 3 symptoms for several days Subthreshold bipolar Recurrent brief depression Major depression lasting < 2 weeks recurring monthly Recurrent psychosis with motility, confusion, anxiety or transcendence Cycloid psychosis
2/3/2020 5 Bipolar Spectrum in the World Mental Health Inititative 61,392 adults in 11 countries Lifetime prevalence in U.S. Bipolar I: 1.0 Bipolar II: 1.1 Subthreshold bipolar: 2.4 Suicide attempts Bipolar I: 25% Bipolar II: 20% Subthreshold bipolar: 10% Severe role impairment Bipolar I: 57% Bipolar II: 57% Subthreshold bipolar: 46% Mental health specialty treatment Bipolar I: 52% Bipolar II: 60% Subthreshold bipolar: 33% KR Merikangas et al: Arch Gen Psychiatry 2011;68:241-251 Covert Bipolar Disorder in Depressed Patients Depressed patients in two primary care practices DSM bipolar disorder: 26.6% Subthreshold bipolar disorder: 31% Number diagnosed by PCP: 0 14% of bipolar patients took a mood stabilizer (all treated by a psychiatrist) 56% of bipolar patients took antidepressants with no mood stabilizer Bipolarity specifier criteria Episode of elevated or irritable mood or increased activity plus 3 or more DSM Criterion B symptoms International study of 5635 adults with a MDE 16% had DSM-IV-TR bipolar I or II Another 31% met bipolar specifier criteria All DSM bipolar patients also met specifier criteria Slide 3 Angst et al: Arch Gen Psychiatry 2011;68:791; Dubovsky et al: Postgraduate Medicine 2011;123:129
2/3/2020 6 Bipolar Outcome of Depression Risk of bipolar conversion highest in 4 years after first depressive episode Afterward conversion rate =1.25%/year

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