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How to guarantee that you would not get well from your Bipolar Disorder Himasiri De Silva, MD Depression and Bipolar Institute, Orange, CA 5/25/2017 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 5/25/2017 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 5/25/2017 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% 5/25/2017 Common Misdiagnoses Unipolar Depression Most Common 60% Anxiety Disorder 62% Schizophrenia 18% Alcohol or Substance Abuse 14% Schizoaffective Disorder 11% 5/25/2017 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% 5/25/2017 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 5/25/2017 Antidepressants have not been shown to definitively prevent completed suicides and reduce mortality, 5/25/2017 Antidepressants should generally be reserved for severe cases of acute bipolar depression and not routinely used in mild to moderate cases. 5/25/2017 Antidepressants have not been shown to be more effective than mood stabilizers in acute bipolar depression 5/25/2017 Antidepressants should be discontinued after recovery from the depressive episode and maintained only in those who repeatedly relapse soon after antidepressant discontinuation. 5/25/2017 Mood stabilizers, especially lithium and lamotrigine, have been shown to be effective in acute and prophylactic treatment of bipolar depressive episodes. 5/25/2017 The risk of antidepressant induced cycling is high. 5/25/2017 There are significant risks of mania and longterm worsening of illness with antidepressants. 5/25/2017 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. 5/25/2017 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 5/25/2017 Research indicates that focused psychosocial treatment protocols for relapse prevention offer significant benefits to patients with bipolar disorder 5/25/2017 Effects of Alcohol Trigger Cover-up Severe symptoms Harder to treat 5/25/2017 Influence of Cannabis on the course of Bipolar Disorder 3459 Bipolar patients enrolled Clinical and Social treatment outcomes were examined over one year 5/25/2017 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 5/25/2017 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 5/25/2017 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 5/25/2017 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. 5/25/2017 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) 5/25/2017 • 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 5/25/2017 • 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 5/25/2017 • 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 5/25/2017 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 5/25/2017 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 5/25/2017 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.