By Bruce Hershfield, MD
[Spring 2006; Vol. 32, No. 3; Pg 3-4]
On
March 25, 2006, an expert panel of psychiatrists lectured on our current
understanding of bipolar disorder and about how we can best treat it. The
day’s activities, co-sponsored by the Maryland Psychiatric Society and by
Sheppard-Pratt(as its 42nd Annual Scientific Day) took place on the hospital’s
campus in Towson. About 250 people attended the meeting.
The
first speaker, Vladamir Maletic, MD, from the University of South Carolina,
described the “spectrum” of the disorder. He made several important points
that were echoed by later speakers. Among them: depression occurs about 12
times as much in Bipolar II as elevated mood does, there is no DSM IV
classification for mixed hypomania even though it is common, bipolar disorder is
often characterized by a mixture of symptoms of mania and of depression instead
of consisting of swings between opposite mood poles, agitated and irritable
depression may actually be a “pseudo-unipolar” depressed mixed state, and
antidepressants may exacerbate the tendency towards mood switches.
Then
Dr. Ross Baldessarini, a Career Investigator at NIMH who is the author of over
1350 publications, lectured about “Clinical Characteristics &
Epidemiology”. Emotional instability is the core feature of bipolar
disorder, he emphasized. The disorder is a “dysregulated condition”
and “mixed” states are the norm. Bipolar II, at least as common as
Bipolar I, is often misdiagnosed and mistreated, he said. As he pointed out, an
“atypical pattern is typical” in bipolar depression--anergia, hypersomnia,
and hyperphagia. Unfortunately, a high percentage of suicide attempts in
patients who suffer from Bipolar II are “successful” ones, and lithium is
the only medication shown to reduce that risk. Bipolar depression is
“the prime therapeutic challenge”, he told us. The course of the
disorder is highly variable, with “acceleration” occurring in about 30% of
cases, and morbidity is “high from the start, even with modern treatment.”
It
was then time to hear about bipolar disorder in children and Dr. Ellen
Leibenluft of NIMH taught us about it. Irritability is the most common
presenting symptom in child psychiatry, she pointed out. She described the
Great Smoky Mountain Study of chronically irritable(“severe mood &
behavioral dysregulation”) children. Those who had this condition at age
nine were seven times more likely to have a depressive disorder when they were
18 than those who had not. In a particularly interesting part of her
presentation, she told us that “anhedonia and euphoria reflect marked
inflexibility in emotional responses, and occur when underlying trait
inflexibility is exacerbated.” What made this so interesting was that
she showed us the ways that the inflexibility can show up on tests, concluding
that “bipolar children have deficits in face emotion identification, response
flexibility and emotion-attention interactions.” The same symptom(chronic
irritability), she said, can have different underlying mechanisms in different
patient populations. In other words, severe mood dysregulation, which is a
predictor of depression in adulthood, differs from bipolar disorder–-they are
“two different roads to irritability”.
The
afternoon’s sessions began with another talk by Dr. Baldessarini–“Bipolar
Disorders Treatment Update”. He provided some particularly useful data
about lithium, e.g. that the best serum level is 0.61-0.75. Because
bipolar disorder presents the highest risk of suicide within psychiatry, it is
important to note that lithium reduces that risk(of attempts and also of
completed suicides) by about 80%. He reviewed the other medications that are
used, including anticonvulsants and antipsychotics. The studies concerning the
treatment of Bipolar II disorder “remain rare”, he mentioned, and,
“despite modern polypharmacy, bipolar disorder patients remain ill 30-40% of
the time, mainly depressed, with increased risk of disability, comorbidity and
death.”
Sheppard-Pratt’s
Scott Aaronson, MD delivered the last of the lectures--” Beyond Pharmacology:
the Clinical Management”. He talked about the economic costs of the
disorder–-including a 14-year work-related loss of productivity–-and the
emotional costs–including the high divorce rate. It is a condition that
is often misdiagnosed; Dr. Aaronson’s opinion is that it is better to
over-diagnose it than to under-diagnose it. Keys that it (instead of major
depressive disorder) is the correct diagnosis include an early age of onset, a
family history of it, a dramatic response to an antidepressant, and a rapid
onset or “offset” of depression. It is, he pointed out, a major health
problem, representing the third-leading cause of premature death or disability
and causing a nine-year reduction in life expectancy.
A
collegial exchange of questions and answers between the audience and the four
panelists concluded the day’s activities.