Transcript Recurrence of bipolar disorder on stopping lithium

If I’m on fire they dance
around it
and cook marshmallows.
And if I’m ice
they simply skate on me
in little ballet costumes
Anne Sexton was a poet
born in the US who suffered
from manic depression
Depression
Low mood (for at least 2 weeks) with
at least 4 of:
disturbed sleep
poor concentration
loss of interest & pleasure
/
reduced appetite & weight loss
agitation or retardation
loss of energy
innapropriate guilt
recurrent thoughts of death
withdrawal
Bipolar Affective Disorder
Is the term used to distinguish those
who have manic episodes from those
who have only (unipolar) depressive
episodes
The relationships with other psychiatric disorders
Symptoms of mania
A change in mood often elated but also irritabilty
This is usually accompanied by
A decreased need for sleep
An increased level of energy and activity
Talking more and quickly – difficult to interupt
Distractibilty
Disinhibition - doing and saying what we usually only think
Overconfidence – can be grandiose to the level of delusions
Impairment of function – at work or in the family or socially
Usually because of irritability or disinhibition
Hypomania is the same symptoms but to a less severe
level and no major impairment in function.
Flight of ideas
“People are cleaning up the house, working very
hard, there’s Flash on the floor. The dog doesn’t
like Flash. There’s a flash in my eye as I’m looking
at the trees, there’s not much oxygen from the
trees. There’s water on the floor, agua. Run the
water, don’t block the sink.”
Digression with loss of goals. Talk uses combinations
of words, sounds and ideas with humour and flippancy
Psychotic symptoms in mania
Delusions are usually grandiose but
often paranoid
Depressive delusions can also be present
particularly in mixed states
A mood clock
Mixed
Mania
Depression
Normal
General Pop
Spouse
Cousin
Uncle/aunt
Unipolar
Grandparent
Bipolar
1/2 sib
One parent
Children
Sibling
DZ Twins
Both parents
MZ Twins
0
20
40
60
80
100
% risk of major affective disorder
Age of Onset in bipolar illness
30
25
No.
of
Patients
20
All
Females
Males
15
10
5
0
-15 20
25
30
Age
35
40
45
50
55
60
Recovery from a manic episode
Kraepelin: “one could hope with great
probability for complete restoration of
health”
?Average untreated length of about 1 year?
– Pollock 1931
Recent studies: 2-3 months
Recurrence of mania
More common than in depressive disorder
– single manic episodes occurred in 2 out of 393
patients in Angst et al 1973
– half will have a recurrence within 2 years
First episode manics
21 patients
15 female : 6 male
(including 5 females post partum)
Average age : 29 years (range 19-47)
Incidence of 5.5 per 100,000 per annum
Prognosis of first episode mania
at two years
10 relapsed (8 manic & 7 depressive episodes)
9 remained well
1 died (murder)
1 not traced
Precipitants of recurrence in
bipolar disorder
Seasonal changes
Personal adversity
Childbirth
Drugs
stop lithium
Childbirth
Life events
Season
Prophylactic efficacy of lithium
in bipolar disorder
2 year placebo controlled study
205 patients on lithium following a manic episode entered trial
on discharge.
Half randomly switched to placebo
Hospitalisation:
placebo
lithium
70/104
31/101
67%
31%
Non relapsed completers at 2 years
11 (10%)
66 (66%)
Prien et al 1973
Tondo et al
2001
Suicide in bipolar disorder
Lifetime risk of 15-20%
Most have been recently (or are) depressed
Often late in the course of illness (15 years) particularly
females
Inadequate (or non compliant) treatment
Isometsa 1994
Lithium and suicide
Mortality by suicide for bipolars is at least x 2-3 higher
than the general population (up to x15?)
a rate of 3.2 per 100 patient years
While on lithium ?similar level of suicides to general
population 0.37 per 100 patient years
Suicide attempts x10 lower in bipolars when on lithium
compared to when not on lithium
Schou 1998