Understanding Bipolar Disorder: Course, Prognosis, and Treatment

 
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To develop an understanding of:
 
the course and prognosis of Bipolar disorder.
risk factors for poor outcomes.
 
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This presentation is based on an APT article:
 
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The paper summarises dozens of articles which are
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?
 
This effects how we think about course, treatment and
prognosis
Studies have generally only dealt with traditional Manic-
Depression (Bipolar 1)
There is less information about other types
 
We must be clear which concept is meant when answering
patients/in exam
Prevalence is 1% (RCPsych – using conventional
concept)
 
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Patients generally have further episodes
Only 16% have definitive recovery
Relapsing/remitting pattern
Length of episodes varies greatly
»
Mania mean episode average - 6 weeks
»
Depression - 11 weeks
»
Mixed affective state - 17 weeks
 
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x2 frequency over uni-polar
Time between cycles shortens for first three, then
stabilises
Risk of suicide 1% annually (Baldessarini 2006)
Polarity of onset may convey prognostic advantages:
unipolar mania at presentation = best
prognosis.
 
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40% depressed on 1
st
 presentation
 
Switch to bipolar higher in the young
»
1% per year >30 y/o
 
Conversion from Bipolar II just 7.5% in 10 years
»
Course is similar but without full manic episodes (>4
days, etc)
 
Rapid cycling (>4 episodes/yr) affects 12-24%
 
 
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Aim is to reduce frequency and intensity
Complete remission is unlikely
30-50% respond to lithium/anticonvulsant when in the
manic phase
Similar rate with atypical antipsychotics
30%  respond to lithium/anticonvulsant in depression
50% with lamotrigine
>50% with quetiapine
 
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Sub-syndromal 15% of the time and minor symptoms
for a further 20% of the time
 
Cognitive functioning can be deficient
Reduced general quality of life
 
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Poor glucose regulation more common
 
Up to 35% obese
 
Thyroid disorders 9% (even in lithium naïve)
 
Migraine more common
 
P
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n
a
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c
y
 
 
Relapse generally said to be 50%
27% of women with bipolar admitted in 1
st
 year
post-partum
 
Non-concordance increases relapse
 
M
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t
a
l
i
t
y
 
 
SMR  overall = 1.6
 
For suicide risk in bipolar SMR = 12.28
 
Medication reduces mortality
 
Lithium shown to decrease suicide
 
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P
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Age at onset is late teens to twenties on average
 
40% of individuals are initially diagnosed with unipolar
depression
 
Bipolar I disorder remains a relatively rare, frequently psychotic
disorder: significant inter-episode cognitive impairment may exist
in the absence of an affective episode
 
Bipolar II disorder is a stable diagnosis, now made more
frequently and associated with a chronic course in which
depression is usually the predominant polarity
 
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Long treatment delays are common (1/3 wait 10 years)
 
Childbirth is associated with high rates of relapse
 
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M
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s
 
B
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4
 
M
C
Q
s
 
1. 
  
Using the broadest definition, prevalence of 
 
bipolar spectrum
 
disorders in the general population has been estimated as high
 
as:
 
A.
0.8%
B.
1.2%
C.
3.9%
D.
8.3%
E.
10.4%
 
B
i
p
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l
a
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4
 
M
C
Q
s
 
1. 
  
Using the broadest definition, prevalence of 
 
bipolar spectrum
 
disorders in the general population has been estimated as high
 
as:
 
A.
0.8%
B.
1.2%
C.
3.9%
D.
8
.
3
%
E.
10.4%
 
B
i
p
o
l
a
r
 
4
 
M
C
Q
s
 
2. 
 
Age at onset of bipolar disorder:
 
 
A.
 
Has little prognostic relevance
 
B.
 
Is not a heritable trait
 
C.
 
Has been observed to be higher in more recent studies
 
D.
 
Is higher in women than men
 
E. 
 
Has implications for clinical course
 
 
B
i
p
o
l
a
r
 
4
 
M
C
Q
s
 
2. 
 
Age at onset of bipolar disorder:
 
 
A.
 
Has little prognostic relevance
 
B.
 
Is not a heritable trait
 
C.
 
Has been observed to be higher in more recent studies
 
D.
 
Is higher in women than men
E
.
 
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a
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4
 
M
C
Q
s
 
3. 
 
Individuals with bipolar disorder:
 
 
A.
 
Rarely receive a diagnosis of unipolar depression
 
B.
 
Have longer episodes of mania than depression
 
C.
 
Commonly have psychiatric co-morbidities
 
D.
 
Have fewer depressive episodes than those with unipolar
  
depression
 
E.
 
Show poorer prognosis if they have predominantly manic
  
episodes
 
B
i
p
o
l
a
r
 
4
 
M
C
Q
s
 
3. 
 
Individuals with bipolar disorder:
 
 
A.
 
Rarely receive a diagnosis of unipolar depression
 
B.
 
Have longer episodes of mania than depression
C
.
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D.
 
Have fewer depressive episodes than those with unipolar
  
depression
E
.
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4
 
M
C
Q
s
 
4. 
 
When compared with bipolar I disorder, bipolar II disorder:
 
 
A.
 
Is associated with better inter-episode functioning
 
B.
 
Is similar and frequently develops into bipolar I disorder
 
C.
 
Is associated with fewer affective episodes overall
 
D.
 
Has a less chronic course
 
E.
 
Has a significantly higher age at onset
 
B
i
p
o
l
a
r
 
4
 
M
C
Q
s
 
4. 
 
When compared with bipolar I disorder, bipolar II disorder:
 
A
.
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B.
 
Is similar and frequently develops into bipolar I disorder
 
C.
 
Is associated with fewer affective episodes overall
 
D.
 
Has a less chronic course
 
E.
 
Has a significantly higher age at onset
 
B
i
p
o
l
a
r
 
4
 
M
C
Q
s
 
5.
 
Regarding the treatment of bipolar disorder:
 
 
A.
 
Delays in initiating treatment are rare
 
B.
 
The vast majority of patients respond to lithium or an
  
anticonvulsant treatment when in a manic phase
 
C.
 
Quetiapine leads to remission in over 50% of patients in the
  
depressive phase
 
D.
 
There are a number of well-tolerated treatments that are
  
effective in all phases of the illness
 
E.
 
The majority of patients are maintained on monotherapies
 
B
i
p
o
l
a
r
 
4
 
M
C
Q
s
 
5.
 
Regarding the treatment of bipolar disorder:
 
 
A.
 
Delays in initiating treatment are rare
 
B.
 
The vast majority of patients respond to lithium or an
  
anticonvulsant treatment when in a manic phase
C
.
Q
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t
i
a
p
i
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e
 
l
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p
h
a
s
e
 
D.
 
There are a number of well-tolerated treatments that are
  
effective in all phases of the illness
 
E.
 
The majority of patients are maintained on monotherapies
 
 
Any Questions?
 
Thank you
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Develop a comprehensive understanding of Bipolar disorder, including its course, prognosis, and risk factors for poor outcomes. Explore the prevalence, time course, and intensity of the disorder, as well as different types and changes in presentation over time. Gain insights from expert-led sessions and delve into research articles for deeper study.


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  1. MRCPsych General Adult Psychiatry Bipolar 4

  2. Bipolar 4 Objectives To develop an understanding of: the course and prognosis of Bipolar disorder. risk factors for poor outcomes.

  3. Bipolar 4 Expert Led Session Bipolar Affective Disorder: Course & Prognosis

  4. This presentation is based on an APT article: Saunders KEA, Goodwin GM (2010). The course of bipolar disorder. Advances in Psychiatric Treatment. 16 (5) 318-328. The paper summarises dozens of articles which are referenced in the original for personal study.

  5. What constitutes Bipolar? This effects how we think about course, treatment and prognosis Studies have generally only dealt with traditional Manic- Depression (Bipolar 1) There is less information about other types We must be clear which concept is meant when answering patients/in exam Prevalence is 1% (RCPsych using conventional concept)

  6. Time course & intensity Patients generally have further episodes Only 16% have definitive recovery Relapsing/remitting pattern Length of episodes varies greatly Mania mean episode average - 6 weeks Depression - 11 weeks Mixed affective state - 17 weeks

  7. Time Course & intensity x2 frequency over uni-polar Time between cycles shortens for first three, then stabilises Risk of suicide 1% annually (Baldessarini 2006) Polarity of onset may convey prognostic advantages: unipolar mania at presentation = best prognosis.

  8. Types & changes in type 40% depressed on 1st presentation Switch to bipolar higher in the young 1% per year >30 y/o Conversion from Bipolar II just 7.5% in 10 years Course is similar but without full manic episodes (>4 days, etc) Rapid cycling (>4 episodes/yr) affects 12-24%

  9. Treatment response Aim is to reduce frequency and intensity Complete remission is unlikely 30-50% respond to lithium/anticonvulsant when in the manic phase Similar rate with atypical antipsychotics 30% respond to lithium/anticonvulsant in depression 50% with lamotrigine >50% with quetiapine

  10. Inter-episode symptoms Sub-syndromal 15% of the time and minor symptoms for a further 20% of the time Cognitive functioning can be deficient Reduced general quality of life

  11. Physical comorbidities Poor glucose regulation more common Up to 35% obese Thyroid disorders 9% (even in lithium na ve) Migraine more common

  12. Pregnancy Relapse generally said to be 50% 27% of women with bipolar admitted in 1st year post-partum Non-concordance increases relapse

  13. Mortality SMR overall = 1.6 For suicide risk in bipolar SMR = 12.28 Medication reduces mortality Lithium shown to decrease suicide

  14. Key Points Age at onset is late teens to twenties on average 40% of individuals are initially diagnosed with unipolar depression Bipolar I disorder remains a relatively rare, frequently psychotic disorder: significant inter-episode cognitive impairment may exist in the absence of an affective episode Bipolar II disorder is a stable diagnosis, now made more frequently and associated with a chronic course in which depression is usually the predominant polarity

  15. Key Points 2 Bipolar-spectrum diagnoses reflect the prevalence of mild elated states but carry uncertain implications for treatment Long treatment delays are common (1/3 wait 10 years) Childbirth is associated with high rates of relapse

  16. Questions or Comments?

  17. MCQs

  18. Bipolar 4 MCQs 1. Using the broadest definition, prevalence of bipolar spectrum disorders in the general population has been estimated as high as: A. B. C. D. E. 0.8% 1.2% 3.9% 8.3% 10.4%

  19. Bipolar 4 MCQs 1. Using the broadest definition, prevalence of bipolar spectrum disorders in the general population has been estimated as high as: A. B. C. D. E. 0.8% 1.2% 3.9% 8.3% 10.4%

  20. Bipolar 4 MCQs 2. Age at onset of bipolar disorder: A. Has little prognostic relevance B. Is not a heritable trait C. Has been observed to be higher in more recent studies D. Is higher in women than men E. Has implications for clinical course

  21. Bipolar 4 MCQs 2. Age at onset of bipolar disorder: A. Has little prognostic relevance B. Is not a heritable trait C. Has been observed to be higher in more recent studies D. Is higher in women than men E. Has implications for clinical course

  22. Bipolar 4 MCQs 3. Individuals with bipolar disorder: A. Rarely receive a diagnosis of unipolar depression B. Have longer episodes of mania than depression C. Commonly have psychiatric co-morbidities D. Have fewer depressive episodes than those with unipolar depression E. Show poorer prognosis if they have predominantly manic episodes

  23. Bipolar 4 MCQs 3. Individuals with bipolar disorder: A. Rarely receive a diagnosis of unipolar depression B. Have longer episodes of mania than depression C. Commonly have psychiatric co-morbidities D. Have fewer depressive episodes than those with unipolar depression E. Show poorer prognosis if they have predominantly manic episodes

  24. Bipolar 4 MCQs 4. When compared with bipolar I disorder, bipolar II disorder: A. Is associated with better inter-episode functioning B. Is similar and frequently develops into bipolar I disorder C. Is associated with fewer affective episodes overall D. Has a less chronic course E. Has a significantly higher age at onset

  25. Bipolar 4 MCQs 4. When compared with bipolar I disorder, bipolar II disorder: A. Is associated with better inter-episode functioning B. Is similar and frequently develops into bipolar I disorder C. Is associated with fewer affective episodes overall D. Has a less chronic course E. Has a significantly higher age at onset

  26. Bipolar 4 MCQs 5. Regarding the treatment of bipolar disorder: A. Delays in initiating treatment are rare B. The vast majority of patients respond to lithium or an anticonvulsant treatment when in a manic phase C. Quetiapine leads to remission in over 50% of patients in the depressive phase D. There are a number of well-tolerated treatments that are effective in all phases of the illness E. The majority of patients are maintained on monotherapies

  27. Bipolar 4 MCQs 5. Regarding the treatment of bipolar disorder: A. Delays in initiating treatment are rare B. The vast majority of patients respond to lithium or an anticonvulsant treatment when in a manic phase C. Quetiapine leads to remission in over 50% of patients in the depressive phase D. There are a number of well-tolerated treatments that are effective in all phases of the illness E. The majority of patients are maintained on monotherapies

  28. Any Questions? Thank you

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