Diagnosing and Treating Bipolar 29


Here we go. Treating Bipolar with antidepressants.
Ineffective. Cause cycle acceleration, it gets worse over time, okay. Provoke mania.
Yet if you look at classes of medications, which class of medications is used most in
the United States to treat Bipolar disorder? Antidepressants. And why? Misdiagnosis. And
treatment of primary care. And maybe I’m being redundant here, but this is not just an academic
question of getting the right answer but this hurts people. And a lot of people- it doesn’t
cause, I mean it can cause mania okay. But for a lot of people it just doesn’t work.
They keep taking it and guess what? They get depressed more often and it gets more severe
and ten years later “oh my god, this person has Bipolar.” And they’ve already had ten
years exposure. Okay, a couple more slides and then we’ll
stop. These are two studies and they’re the best around in terms of looking at it over
a longer span of time and 13 year follow up studies, these are people with Bipolar 1,
classic manic depressive illness that has manias and depressions. And look at this,
these are people in treatment, who are being followed up for 13 years, in treatment okay,
and 47% of the weeks, so 47% of their life, they were symptomatic. And here’s the breakdown.
And so what we have here is that ⅔ of the times they’re symptomatic it’s depression
and about a third it’s some version of mania. With Bipolar 2 it’s even worse and it’s worse
for a couple of reasons okay. Now first off, some people say ‘okay Bipolar 2 is a less
severe version’ and in one respect that’s true because they don’t have these horrible
manic episodes which can be catastrophic, they can ruin peoples lives. But over the
long haul you have higher suicide rates and higher divorce rates with Bipolar 2 and the
reason for this is because of this, look at this. They are symptomatic even more of the
time and almost all of that is depression. More than 50% of the time they’re in states
of depression and that really takes a toll in terms of marriages and increase in suicide
risk. And if you happen to have hypercortisolemia along with your depressions, you’re walking
around being exposed to toxic levels of cortisol for years. And that’s why you have brain damage
with Bipolar disorder that’s significant and also, did I mention last time Vascular disease?
Did I mention that in our last class? hypercortisolemia? And they have twice the death rate of heart
attacks than they do in the general population. Okay Diagnostic Issues. Okay, let’s go through
these and then we’ll stop. High index of suspicion. First off, this is really important to look
at, family history, okay because it’s hard to find someone with Bipolar disorder who
doesn’t have a large number of relatives that have severe mood disorders. Now obviously
sometimes people don’t know about their relatives. Most people don’t know if their great aunt
had Bipolar disorder, but they might know ‘yeah Uncle Tom he was a drunk. He died of
Cirrhosis at like forty. You know he’s in and out of the hospital.’ ‘Oh yeah my great
grandmother was in and out of state hospitals or great aunt Suzie killed herself when she
was 32.’ Now none of these alone necessarily means that they had Bipolar, but you get a
family history and it’s like ‘wait a minute, a whole bunch of these people having a bunch
of this stuff.’ It increases your index of suspicion. Next thing is hyper-thymia, which
is a chronic hypomania. And if I had to be stricken with any psychiatric disorder, this
would be my choice. I know somebody like this, my wife’s best friend has this and god she’s
outgoing and gregarious and sleeps five hours a night and is never sleepy and uh it’s like
if you add some ambition and IQ points in here look out. These people go to town. And
they don’t need treatment. They don’t come in and say ‘god help me’ you know? They do
however come in for marriage counseling a lot of times because one problem is that they
tend to be kind of irritable. They’re upbeat but they’re also kind of irritable and really
get frustrated when people can’t keep up with them. “What’s the matter with you? You don’t
wanna go out for the sixth time this week and go dancing?” That kind of thing. Okay
but the reason this is here is not because this by itself is psychopathology but it counts
okay. And it’s not unusual to get a kid who’s Bipolar and their dad’s got this. Okay so
it’s coming out of that same genetic vulnerability. Okay let’s see. Childhood onset of depression.
Post-partum onset, post-hysterectomy, if the depressions occur early in life or if they
follow here, especially if you don’t have a history of premenstrual dysphoria. A lot
of times peoples first episode of Bipolar is after they give birth to a baby. Treatment
resistant to antidepressants. Most people come in and say ‘I’ve taken all these antidepressants
and none of them work.” 4 out of five of them never took the drugs long enough for them
to work or at high enough doses. What we’re talking about here, is that they’ve taken
really hefty doses for weeks. And they’ve tried three different drugs. And none of them
worked. That’s a huge red flag okay. Sometimes, history of a response to antidepressants but
then it poops out after a month or two. It’s not clear what’s going on here, probably a
placebo response to their depression. Now most people with Seasonal Affect Disorder
don’t have Bipolar. But a lot of people with Bipolar have seasonal mood changes. Major
depression with racing thoughts. Psychotic symptoms with their depression okay. If a
person is having episodes of depression that occur more than one time a year, almost all
of them have Bipolar. They have Bipolar 3, which I’ll talk about next time. And finally,
I’ve already talked about this, are Atypical symptoms. You see hypersomnia, sleeping twelve
hours a day, tired all the time. Often increased appetite, weight gain. That triad, especially
hypersomnia. This was a European study but there was in the United States. Same result,
basically about 4 out of 5 of them have Bipolar 2. OK, so that’s kind of the checklist to
go through. And two things that stand out big are family history and Atypical symptoms.
And I think before you give an antidepressant out to anybody, you’ve got to walk through
and really check and make sure. And remember a lot of these bipolar folks have had something
bad happen you know. Their marriage breaks up, they lose their house or foreclosure or
something and they get depressed and it looks like a reaction to depression, can happen
just as likely in someone with Bipolar as someone with Unipolar. So the fact that it’s
in response to a life stressor does not mean they don’t have Bipolar.

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