Transcript Document

How to guarantee that you
would not get well from your
Bipolar Disorder
Himasiri De Silva, MD
Depression and Bipolar Institute, Orange, CA
7/17/2015
Inaccurate or Inadequate Diagnoses
 Two research studies by National Depression and Bipolar Alliance
in yrs. 1992 and 2000
 600 patients studied.
 Findings were very similar
7/17/2015
Prevalence of Misdiagnosis
Misdiagnosis
69%
Of those Misdiagnosed:
Misdiagnosed 1-3 Times
70%
Misdiagnosed 4-6 Times
14%
It was Necessary to Consult 4
Physicians Before Correct Diagnosis
7/17/2015
Lapsed Time: Seeking Help to
Accurate Diagnosis
•1992
•2000
•Misdiagnosed #
•(363)
•(411)
• < 1 yr.
•14%
•20%
•
1 yr. to 3 yrs.
•17%
•17%
•
3 yrs. to 5 yrs.
•9%
•11%
• 5 yrs. to 10
yrs.
•15%
•16%
• >10 yrs.
•41%
•35%
7/17/2015
Common Misdiagnoses
Unipolar Depression Most Common
60%
Anxiety Disorder
62%
Schizophrenia
18%
Alcohol or Substance Abuse
14%
Schizoaffective Disorder
11%
7/17/2015
Why Incorrect Diagnosis?
 Lack of Understanding
14%
 Symptoms not Taken Seriously60%
60%
39%
 Lack of Communication
 Patients did not Report All
 Lack of Support from Family / Friends
 Did not go to Mental Health Professional
 Lack of Communication Among Doctors
37%
28%
23%
17%
3%
7/17/2015
Treatment Issues
 Inaccurate Diagnosis leads to less than ideal treatment
 Mood Stabilizers are often ignored
 Antidepressants are often used
 Not following guidelines may affect the course of illness.
 Patients may not use the available information to care
for themselves
7/17/2015
Antidepressants
have not been
shown to
definitively
prevent
completed
suicides and
reduce mortality,
7/17/2015
Antidepressants
should generally
be reserved for
severe cases of
acute bipolar
depression and
not routinely used
in mild to
moderate cases.
7/17/2015
Antidepressants
have not been shown
to be more effective
than mood
stabilizers in acute
bipolar depression
7/17/2015
Antidepressants should
be discontinued after
recovery from the
depressive episode and
maintained only in those
who repeatedly relapse
soon after
antidepressant
discontinuation.
7/17/2015
Mood stabilizers,
especially lithium and
lamotrigine, have been
shown to be effective in
acute and prophylactic
treatment of bipolar
depressive episodes.
7/17/2015
The risk of
antidepressant
induced cycling is
high.
7/17/2015
There are
significant risks of
mania and longterm worsening of
illness with
antidepressants.
7/17/2015
Effects of Psychotherapy
 Application of Psychotherapy is encouraged by the
effects of psychosocial stresses on the course of Bipolar
Disorder
 Research supports the efficacy of psychosocial treatment
delivered in Individual, family and group settings.
7/17/2015
 Elements of such treatments include Psycho-education,
Communication and Problem solving training
 Strategies for early detection and intervention are
commonly combined with cognitive restructuring as well
as stress and lifestyle management interventions
7/17/2015
 Research indicates that focused psychosocial treatment protocols
for relapse prevention offer significant benefits to patients with
bipolar disorder
7/17/2015
Effects of Alcohol
 Trigger
 Cover-up
 Severe symptoms
 Harder to treat
7/17/2015
Influence of Cannabis on the course of
Bipolar Disorder
 3459 Bipolar patients enrolled
 Clinical and Social treatment outcomes were examined over one
year
7/17/2015
Results
Cannabis users showed
 less compliance
 Higher levels of severity
 More Mania and Psychosis than non users
 Less satisfied with their lives
 Less chance of forming relationships

Winter-Van Rossum et all, Netherland 2010
7/17/2015
Effects of stress and social support
on
Bipolar Disorder
Method
 support score assessed from supporting individuals or
groups
 Stressful life 52 outpatients with Bipolar Disorder were
followed every three months for one year
 Total network events assessed
 Medication compliance established
7/17/2015
Results
 Both higher levels of stress and lower levels of social
support predicted depressive recurrence over one year
follow up.
 Social support did not moderate the impact of stress
Cohen A.N, Hammen C,Henry RM, Daley SE 2004
J. Affective Disorders
7/17/2015
Effects of Peer Support Groups for
people with Bipolar Disorder
 Social support has been associated with good health, well-being
and functional performance of individuals with BD
 This type of social networks are at a greater risk due to variety of
reasons, including socially undesirable behavior when the patient
is manic or depressed.
7/17/2015
Topics discussed
• Medication (values, benefits, side effects)
• Early warning signs (what they are when noticeable? when to act?
what to do and where to seek help?)
• Nutrition for the mind (use of food and supplements that affect
mood)
7/17/2015
• Cognitive-behavioral therapy
• Spiritual well-being
• Life style issues (e.g., energy level, sleep pattern, diet, opportunity
for making life-style changes)
• Managing family (spouse/ partners, children) and friend
relationships
7/17/2015
• Alternative treatments (what have people heard? where to get
information?)
• Dealing with discrimination and stigmatization (how to deal with?
what to say?)
• Diagnosis and its replications
• Housing
• Employment
7/17/2015
• Talks from other non-government organizations about the services
they provided
• Talks by health professionals, social welfare agencies and income
support services
• Privacy law
• Educational video on people’s recovery journey
• Update on changes in mental health services or system
• Report on national organizations and conferences
7/17/2015
Conclusions and
recommendations:
 Accurate Diagnosis
 Treatment plan using guidelines
 Psychotherapy in addition to medications
 Minimize stress and improve coping skills
 DO NOT ABUSE ALCOHOL OR DRUGS
 Participate in support groups
 Learn as much as you can about BIPOLAR DISORDER
7/17/2015
FDA-approved Indications of Agents Used in
the Treatment of Adults With Bipolar Disorder
Bipolar Depression
Agents
Acute
Treatment
Bipolar Mania
Mixed State
Maintenance
Treatmenta
Acute
Treatment
Maintenance
Treatmenta
Acute
Treatment
Maintenance
Treatmenta
√b
√b
√
√
√
√
√
√
√
√
√b
√b
√
√
√
√
√b
√b
ATYPICALS
Aripiprazole (Abilify)
Olanzapine (Zyprexa)
Quetiapine (SEROQUEL)
Quetiapine (SEROQUEL XR)
√
√
Risperidone (Risperdal)
Ziprasidone (Geodon)
√
√
√
OTHER
Carbamazepine ER (EquetroTM)
Divalproex DR (Depakote)
Divalproex ER (Depakote ER)
√
Lamotrigine (Lamictal)
Lithium (Lithobid, Eskalith)
Olanzapine/fluoxetine (Symbyax)
√
√
√
√
√
√
√
c
√
√
√
This chart does not imply comparable efficacy or safety profiles. Some of the products listed above are also approved in other age
groups, for additional indications, and/or available as an injection. All brand names and product names used in the chart are
aBased
trademarks
of their
respective
As of 1/09.
on FDA-approved
indications
andowner.
index episodes
of responding patients enrolled in bipolar maintenance trials.
The bipolar maintenance studies for aripiprazole and olanzapine enrolled patients whose most recent (index) episode
was manic or mixed. The SEROQUEL bipolar maintenance trials enrolled patients whose most recent episode was
manic, depressed, or mixed. SEROQUEL XR was approved for the maintenance treatment of bipolar I disorder on the
basis of extrapolation from the established effectiveness of SEROQUEL.
bSEROQUEL and SEROQUEL XR are approved for the maintenance treatment of bipolar I disorder as adjunct therapy
7/17/2015
to lithium or divalproex.
cMaintenance indication for lamotrigine (Lamictal ®) also includes hypomania.
Data on file, 272661, AstraZeneca Pharmaceuticals LP.
SEROQUEL XR® (quetiapine fumarate) Extended-Release Tablets. Prescribing
Information.