major depressive disorder is also known as
unipolar depression
chronic depression mood symptoms
- includes fatigue, low motivation, anhedonia, changes in appetite & sleep, rumination, suicidality.
- Co-morbid with anxiety disorders, high lifetime prevalence (approx. 15-20%)
bipolar disorder is also known as
bipolar depression
how many types of bipolar disorder
three, depending on the amount of time a person spends in mania and the severity of the symptoms
bipolar disorder is characterized by
more than one bipolar episode– a week or more- of alternating mania and depression
bipolar disorder type 1
The primary symptom presentation is mania, or rapid (daily) cycling episodes of mania and depression.
bipolar disorder type 2
The primary symptom presentation is recurrent depression accompanied by hypomanic episodes (a milder state of mania in which the symptoms are not severe enough to cause marked impairment in social or occupational functioning or need for hospitalization, but are sufficient to be observable by others)
BP2 Mania episodes are
A distinct period of abnormally and persistently elevated, expansive, or
irritable mood, lasting at least 1 week (or any duration if hospitalization is
necessary)
BP2 mania episodes are characterized by
(1) increased self-esteem or grandiosity
(2) decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
(3) more talkative than usual or pressure to keep talking
(4) flight of ideas or subjective experience that thoughts are racing
(5) distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
(6) increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
(7) excessive involvement in pleasurable activities that have a high potential
for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
Depressive episodes are characterized by
- Depressed mood most of the day.
- Diminished interest or pleasure in all or most activities.
- Significant unintentional weight loss or gain.
- Insomnia or sleeping too much.
- Agitation or psychomotor retardation noticed by others.
- Fatigue or loss of energy.
- Feelings of worthlessness or excessive guilt.
- Diminished ability to think or concentrate, or indecisiveness.
- Recurrent thoughts of death and suicide.
is there a genetic component to BPD
- Strong genetic component (70-80%) but genetics are complex - no single gene causes BPD.
- Genetic susceptibility for bipolar disorder shares more in common with schizophrenia than unipolar (MDD).
prevalence of BPD
1-2% (equal between men and women)
onset of BPD
post-adolescent / early adult
T/F BPD can worsen without treatment
True
co-morbidities of BPD
ADHD, anxiety disorder, substance abuse, obesity and metabolic syndrome (T2D, cardiovascular disease, dyslipidemia), Suicidal thoughts 80% - attempt 50% - complete 15%
treatment for BPD
- Treatment strategies are complicated – mix of mood stabilizers, antipsychotics, and antidepressants.
- Lifestyle changes and psychotherapy are important components of treatment
triggers for mania
- Triggers for mania include sleep-deprivation and changes to sleep routine, amphetamine and other stimulants, life stress (positive and negative), changes to daily routine.
- Triggered by lack of sleep
- Major change
- Drama / trauma
- Really good things
pharmacotherapies for BPD
- Combinations of several medicines that depend on the symptoms of the patient (mood stabilizers with antidepressants and antipsychotics).
- Mood stabilizers – most commonly prescribed are lithium and valproate.
- Best mood stabilizer = lithium salt (lithium carbonate)
○ Mechanism of action is unknown it appears to block downstream signaling events that occur when dopamine receptors are activated…
acute adverse effects of lithium
○ Dry mouth, metallic taste, thirsty, frequent urination, headache, shaky hands
○ Nausea vomiting confusion
○ Chronic
○ Thyroid problems – insufficient thyroid hormone production
- Kidney toxicity – when kidney function is reduced, people must discontinue lithium
lithium is known to have a
“narrow therapeutic window”. This means that the dose needed to treat the disease is close to the dose that causes toxicity. Blood levels of lithium are monitored to make sure people are in the safe range.
Valproic Acid (valproate) BPD
- Anticonvulsant mood stabilizer = valproic acid (valproate)
- Valproate blocks voltage-gated sodium channels – required to propagate action potentials along the axon.
- Valproate also changes gene expression and increases the amount of GABA (inhibitory neurotransmitter) that is produced.
- How this helps with bipolar disorder is unknown.
In summary – we know part of the mechanism of action for valproic acid. We know how it affects voltage gated sodium channels. We know that it increases the levels of GABA neurotransmitter. These things both decrease neuron firing
what are other anti-convulsant mood stabilizers
lamotrigine and carbmazepine
what are these anticonvulsant medications used for
- These are drugs that are used in epilepsy and also act as mood
stabilizers in BPD. They have multiple targets (blocking glutamate receptors, blocking calcium channels, and others). - Their mechanism for treating BPD is unknown.
- Lamotrigine is considered a depressive mood stabilizer (used to
treat depression in bipolar disorder). - Carbamazepine is considered a manic mood stabilizer (used to
prevent mania episodes).
pharmacotherapies for BPD
- Antidepressants (only in combination with a mood stabilizer or antipsychotic)
- Antipsychotic medications (second generation)
- Quetiapine may be used alone since it seems to have some anti-depressant
properties in bipolar disorder as well as being an antipsychotic. - Quetiapine is a “second generation” antipsychotic.
