Depression bipolar disorder-related

A potential limitation of most of the controlled studies discussed above relates to the numerous exclusion criteria used for patient selection. For example, in order to find homogenous samples, major depression, bipolar disorder, Tourette s disorder, psychosis (clomipramine, fluvoxamine and fluoxetine trials), primary psychiatric disorder other than OCD (clomipramine and sertraline trials), and attention deficit/hyperactivity disorder (ADHD), autism, or other developmental disorders (clomipramine and fluoxetine trials) were excluded. Thus it remains unknown how well these controlled studies will generalize to more naturalistic clinical populations that are highly comorbid and where exclusion criteria are not applied. 

Modem psychiatric treattnents were introduced in 1949, when lithium carbonate was discovered as treatment for mania by Australian psychiatrist John F. Cade (Figure 1.45). After Cade s initial report, lithium therapy was principally developed in 1954 by Mogens Schou (Aarhus University, Denmark). In 1969, 20 years after its discovery by John Cade and after a decade of trials, the Psychiatric Association and the Lithium Task Force recommended lithium to the FDA for therapy of mania. A breakthrough had been achieved in the treatment of manic depression, and the genetically related forms of recurrent depression. Bipolar disorders, which afflict about 1% of adults, are now treated with drugs called mood stabilizers, especially lithium and valproic acid, both discovered decades earlier, but nothing better has yet emerged. ... 

The association between the use of antiepileptic drugs and suicide-related events (attempted suicide and completed suicide) in patients with epilepsy, depression, or bipolar disorder has been studied in 5130 795 patients [66 ]. The incidence of suicide-related events per 100 person-years was 15 among patients without epilepsy, depression, bipolar disorder, or antiepileptic drug treatment, 382 among patients with epilepsy who did not take antiepileptic drugs, and... 

Bipolar disorders have been categorized into bipolar I disorder, bipolar II disorder, and bipolar disorder, not otherwise specified (NOS). Bipolar I disorder is characterized by one or more manic or mixed mood episodes. Bipolar II disorder is characterized by one or more major depressive episodes and at least one hypomanic episode. Hypomania is an abnormally and persistently elevated, expansive, or irritable mood, but not of sufficient severity to cause significant impairment in social or occupational function and does not require hospitalization. Most epidemiologic studies have looked at bipolar disorder of all types (bipolar I and bipolar II), or the bipolar spectrum, which includes all clinical conditions thought to be closely related to bipolar disorder. The lifetime prevalence of bipolar I disorder is estimated to be between 0.3% and 2.4%. The lifetime prevalence of bipolar II disorder ranges from 0.2% to 5%. When including the bipolar spectrum, the lifetime prevalence is between 3% and 6.5%.1... 

Disturbances of sleep are typical of mood disorders, and belong to the core symptoms of major depression. More than 90% of depressed patients complain of impaired sleep quality [60], Typically, patients suffer from difficulties in falling asleep, frequent nocturnal awakenings, and early morning awakening. Not only is insomnia a typical symptom of depression but, studies suggest, conversely, insomnia may be an independent risk factor for depression. In bipolar disorders sleep loss may also be a risk factor for the development of mania. Hypersomnia is less typical for depression [61] and, in contrast to insomnia, may be related to certain subtypes of depression, such as seasonal affective disorder (SAD). 

The term "bipolar disorder" originally referred to manic-depressive illnesses characterized by both manic and depressive episodes. In recent years, the concept of bipolar disorder has been broadened to include subtypes with similar clinical courses, phenomenology, family histories and treatment responses. These subtypes are thought to form a continuum of disorders that, while differing in severity, are related. Readers are referred to the Diagnostic and Statisticial Manual of Mental Disorders of the American Psychiatric Association (DSM-IV) for details of this classification. 

These authors also found that 65% (New York) and 67% (Ohio) of the sampled medicated patients who received an antipsychotic prescription were not diagnosed with a psychotic disorder. Similarly, 0% and 20% of the sampled medicated patients who received a stimulant medication were not diagnosed with ADHD, and 27% and 42% of the sampled medicated patients who received antidepressants were not diagnosed with major depression, dysthymia, bipolar disorder, or related conditions. In discussing the appropriateness of the medication treatments in the survey, the authors concluded that approximately 10% of the treatments in each sample were deemed inappropriate. 

The rates of provocation of mania reported with SSRIs appear to be lower than rates with the TCAs and may therefore be a more appropriate therapeutic option in the treatment of depression in patients with bipolar disorder. It is of course difficult to distinguish the beneficial effect of a drug in relation to rare events, but the meta-analysis of the database of one of the SSRIs reported a switch rate of between 2% and 3%, which compares favorably with 11% reported with TCAs [S. A. Montgomery 1995d). 

Older persons account for one-third of all suicides in the United States even though this group represents only 12% of the population ( 36). Suicide is even more often related to major depression in the elderly than in younger individuals in whom other causes such as substance abuse, bipolar disorder, schizophrenia, and personality disorders often play a major role. In fact, suicide rates are highest in older white men relative to any other segment of the population. For example, white men older than 85 years age commit suicide 30 times as frequently as black women. 

Blumenthal et al. (15) reported that psychotic features in both unipolar and bipolar disorders were indicative of an earlier age of onset and first hospitalization in comparison with their nonpsychotic counterparts. Age of onset for the first episode was found to be earlier in the bipolar group regardless of psychotic categorization. Furthermore, the authors hypothesize that delusional depressions may be related to bipolar disorder, given a higher prevalence of the latter in relatives, and postulate a predictive relationship between psychoticism and bipolarity. 

One family study indicated that the schizoaffective-manic type tended to aggregate with classic bipolar disorder, while the schizoaffective-depressive type seemed to be more closely related to schizophrenia ( 37). 

The sequence, number, and intensity of manic and depressive episodes are highly variable. The cause of the mood swings characteristic of bipolar affective disorder is unknown, although a preponderance of catecholamine-related activity may be present. Drugs that increase this activity tend to exacerbate mania, whereas those that reduce activity of dopamine or norepinephrine relieve mania. Acetylcholine or glutamate may also be involved. The nature of the abrupt switch from mania to depression experienced by some patients is uncertain. Bipolar disorder has a strong familial component, and there is abundant evidence that bipolar disorder is genetically determined. 

An effective treatment for bipolar disorder (manic -depressive illness) is the administration of lithium salts 445/1111-11133 Inhibition of the hydrolysis of inositol phosphate by Li+ (Fig. 11-9) may be related to its therapeutic effect. Reduced phosphatidylinositol turnover may dampen responses to neurotransmitters.1114 Li+ may affect gene expression in neuropeptide-secreting neurons.1115 Bipolar disorder apparently has more than one cause. There are strong indications of genetic susceptibility,1116 and genes that increase susceptibility have been located on chromosomes 4,12,13,18,21, and X.1117... 

First, atypical antipsychotics undoubtedly cause far fewer EPS than do conventional antipsychotics and often cause essentially no EPS (i.e., they really do perform in this respect, as predicted pharmacologically and as advertised). Second, atypical antipsychotics reduce negative symptoms of schizophrenia better than do conventional antipsychotics, but this may be because they do not make things worse as much as because they really reduce negative symptoms. The magnitude of this effect is not as robust as the effects on EPS, and further innovations will be necessary to solve the negative symptom problem in schizophrenia—nevertheless, this is a good start. Third, atypical antipsychotics reduce affective symptoms in schizophrenia and related disorders such as treatment-resistant depression and in bipolar disorder, where treatment effects appear to be quite robust. Fourth, atypical antipsychotics may... 

Several medical, medication-induced, or substance-related causes of mania and depression have been identified (see Table 68-2 for causes of mania and Table 67-1 in Chap. 67 on depressive disorders for causes of depression). " A complete medical, psychiatric, and medication history physical examination and laboratory testing are necessary to rule out any organic causes of mania or depression. An accurate diagnosis is important because some psychiatric and neurologic disorders present with manic-like symptoms. For example, attention-deficit/hyperactivity disorder and a manic episode have similar characteristics thus individuals with bipolar disorder may be misdiagnosed and prescribed central nervous system stimulants. Use of any substance that affects the central nervous system (e.g., alcohol, antidepressants, caffeine, central nervous system stimulants, hallucinogens, or marijuana) can worsen symptoms and decrease the... 

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