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13 Feb 2008

Bipolar Disorder

CBS CARES: What exactly is "bipolar disorder" and how does it differ from depression?

DR. OQUENDO: Bipolar disorder, as currently defined in the Diagnostic and Statistical Manual of Mental Disorders, consists of three subsets:

First, there is "bipolar disorder one." This is a disorder that has been recognized since the turn of the last century and is also known as manic depression. It's characterized by episodes of major depression, for example; depressed mood, difficulty enjoying oneself, difficulty in sleeping and eating, low energy, problems with concentration, suicidal ideation, et cetera. But in addition to having episodes of depression, people with manic depression, or bipolar disorder one, also have episodes of mania or up-swings in mood. In mania, the presentation is one of either euphoria or extreme irritability.

Then, there is "bipolar disorder two." This is a more subtle form of the illness, in that the person still has episodes of major depression, but on the other side of the coin, there is hypomania. The up-swings never reach the same magnitude as they do in full mania, so that patients with bipolar disorder two have episodes of what we refer to as hypo-manic episodes, where they have some of the symptoms for mania, but in a much more attenuated fashion. One of the difficulties of this disorder is that the subtlety of those symptoms can often make it hard to diagnose.

The third type of bipolar disorder, which is what's being included in so-called "bipolar spectrum disorder," is "bipolar disorder NOS" ("Not Otherwise Specified"). This is a diagnostic criterion that's available when the clinician sees a patient who he or she believes has a bipolar condition, but doesn't strictly meet the criteria of either bipolar disorder one or bipolar disorder two. So that's where the word "spectrum" is utilized, to refer to this type of problem.

So it is the episodes of either manic or hypo-manic episodes that separate bipolar from depression.

CBS CARES: Can you further describe manic episodes?

DR. OQUENDO: Manic episodes are episodes in which the person finds him or herself feeling very euphoric and exuberant, often times accompanied by significant irritability. The person shows difficulty with impulse control, acting in ways that are uncharacteristic in terms of sexual activity, or spending money. They also often do not require very much sleep, they might be feeling especially creative, be very energetic, they might speak very quickly and they may move around very quickly. They may have feelings to such an extent that they believe that they have supernatural powers or that they are a special human being, but not in the way that we would ordinarily think of that word. They might think that, for example, they have been sent by God to save the world or something of that nature. In other words, it is a very dramatic presentation and often times this type of illness is extremely disruptive to this person's life, particularly because they do things that are impulsive and often times in a public kind of way that later can be quite embarrassing to them.

CBS CARES: And "hypo-manic episodes" are more subtle?

DR. OQUENDO: Exactly, hypo-manic episodes are much more subtle than manic episodes. Often times they have very similar symptoms, but by definition they cannot be as impairing. In other words, the person often times is functioning at their work or at home, but people around them notice that there's something markedly different about them.

CBS CARES: If "hypo-mania" borders on extreme enthusiasm, energy and creativity and the person can still be functional, is it fair to say that it can also be a characteristic that may account for some people's success and persistence against all odds?

DR. OQUENDO: Well, I think that that's something that's been observed for centuries. Some of the most productive and creative individuals suffer from this type of illness.

CBS CARES: How long do the manic and hypo-manic episodes usually last?

DR. OQUENDO: The average manic episode will last anywhere from one to four months.

CBS CARES: How many people in the United States have been diagnosed with any of these forms of bipolar disorder and how many new cases are there in a typical year?

DR. OQUENDO: It's estimated that about 11.5 million Americans suffer from bipolar disorder and about 55,000 new cases are diagnosed each year.

CBS CARES: Why has the number of people diagnosed with bipolar disorder increased?

DR. OQUENDO: I think that the complexity that is part of the disorder has led to an increase in the number of terms that are used to describe it. For example, it used to be that there was just bipolar disorder. In the mid '80s, it was recognized that there were sub-forms of bipolar disorder and the terms bipolar disorder one and bipolar disorder two became commonly used. Later on in the early '90s, bipolar disorder NOS began to be used. And some people refer to manic episodes that are induced by either medication or other substances, such as drugs (like cocaine, for example) as being a type of bipolar disorder that they term bipolar three. So yes, there has been a proliferation in the types of diagnoses, but I think of them more as subtypes as opposed to different diagnoses. As we understand more about the biology of these disorders, we may in fact determine that these are actually separate illnesses.

CBS CARES: So basically, the numbers have increased in large part because the definition has expanded.

DR. OQUENDO: Yes, possibly.

CBS CARES: Earlier when you described the third category of "bipolar disorder NOS" it sounded very fluid …doesn't that leave room for some psychiatrists to subjectively, but wrongly, diagnose someone as "bipolar"?

DR. OQUENDO: It allows flexibility for the clinician to use their judgment about whether the patient has some features consistent with a bipolar spectrum. It is possible that less definitive criteria such as the ones in bipolar NOS can lead to misdiagnosis, but having this kind of diagnosis available is a good way to try to deal with the reality that psychiatric conditions are not easy to put into neat little boxes.

CBS CARES: It's been said that sometimes, doctors, psychiatrists, and psychologists focus more on the depression part of bipolar disorder and may miss the manic…euphoric… component. Is this true, in your opinion? And if so, why does it happen?

DR. OQUENDO: Yes. I believe that this is especially the case for bipolar two, for two different reasons. One is that patients who have bipolar disorder two tend to spend the bulk of their time in depressive episodes as opposed to hypo-manic episodes. And the other is that the diagnosis of hypo-mania can be difficult to make, not only because the symptoms are subtle, but often because the patient does not perceive them as being abnormal or anything that requires attention. On the contrary, they feel pleased when they feel more energetic and productive and confident and all of the things that go with feeling hypo-manic, which are typically considered by the patient quite positive.

CBS CARES: Is it accurate to say that a misdiagnosis of depression, when someone in fact has bipolar disorder, can be a very serious mistake, because the treatment for bipolar disorder is very different than for depression alone?

DR. OQUENDO: This is a critical point. In bipolar disorder, it is absolutely critical that the person be treated with a mood stabilizer even if they are currently depressed. The standard of treatment, even in depressed bipolar patients, is for them to be on a mood stabilizer and if necessary, which it often is, also on an anti-depressant. The reason for this is that if you put a patient with bipolar disorder on an anti-depressant alone, there is a risk for triggering a manic episode or a hypo-manic episode. If it's hypo-manic, it's not so bad. But if the person is manic, they may require hospitalization and/or do things that are self-destructive.

CBS CARES: What are the other obstacles to proper diagnosis and treatment?

DR. OQUENDO: The main roadblock to diagnosis has to do with two things. One is the problem with the patient not necessarily recognizing the pathology that is linked to hypo-manic or even manic states. The patient often doesn't think there's anything wrong with him or her, so they might not report it spontaneously. And secondly, it is sometimes the case that the patient presents to treatment when they're depressed, and the therapist or psychiatrist forgets to ask, not about whether the person has ever been manic, but about the particular symptoms.

Things that, for example, a patient might report without prejudice involve sleep. So, I often ask people, "Have you ever had a period of time when you didn't need to sleep very much, but you were still really, really energetic and you felt fine?" And that's often a very good way to get the person talking about the illness because it's almost always the case that the person has problems with decreased sleep. They don't perceive it as a problem, but they know that they have decreased sleep. And it opens the door to asking about other symptoms. If you ask the patient, "Have you ever had a point in your life when you felt especially good or euphoric," they may not consider that abnormal, and they wouldn't report it as a symptom.

CBS CARES: So to increase the chance of accurately diagnosing whether it's bipolar disorder or depression, does the role of the family become important in that they can give a perspective on the patient's mood swings that the patient may not always realize?

DR. OQUENDO: In my opinion, it's absolutely critical to speak to family members about symptoms, in particular in these types of disorders where some symptoms may not be apparent to the patient, him or herself.

CBS CARES: Is that typically done by telephone or should the therapist meet with the family in person?

DR. OQUENDO: Well, especially in younger individuals, it is typical to actually have a meeting with the family to obtain information about the youngster. This is especially true in children and adolescents of course, but even in young adults. I think for adults, in general, it's more common to speak to the family by phone than to see them in person. But of course there's almost no substitute for meeting people in person, when possible.

CBS CARES: Why is the average age of bipolar diagnosis much lower now than say ten years ago?

DR. OQUENDO: It used to be that this disorder was diagnosed in late adolescence, or early adulthood, usually in the nineteen to twenty-six years age range. Many are now being diagnosed in adolescence. There are three possible explanations for the change. One is that it is possible that physicians are more aware of the symptoms of bipolar disorder, especially the more subtle symptoms of bipolar disorder and are making the diagnosis earlier, before it becomes as dramatic as it can be.

The other possibility is that there is a tremendous amount of confusion about the diagnosis of children. There seems to be a lot of overlap with other disorders, including attention deficit disorders and oppositional defiant disorders. And right now, there is a raging controversy in child psychiatry about what constitutes bipolar disorder in children and adolescence, and it's really an open question.

CBS CARES: How do you accurately diagnose bipolar disorder in children, when they may not understand all the diagnostic questions and when fantasies, delusions and boundless energy are a natural part of being a child?

DR. OQUENDO: Well, I have to say that I would defer to a child psychiatrist on this. However, I think that one of the critical things, in terms of our being able to adequately treat patients is to make sure that they meet criteria in terms of duration and symptoms clustered together. So, one of the things that's happening, for example, is that at times children may be diagnosed without meeting the length of time required in a manic episode. If somebody has a manic episode that lasts more than four hours, they might be diagnosed as bipolar, whereas that is not typically the way the diagnosis is made. In terms of making a distinction between normal fantasy and delusions or the natural ebullience of childhood and pathologically increased energy, one key is that if there is a manic episode going on, the symptoms will be an obvious change from the child's usual behavior. Furthermore, children over the age of about 6 or 7 can distinguish between what is real and what is not.

CBS CARES: Does depression in teen years indicate a strong possibility of bipolar disorder later in life?

DR. OQUENDO: That's a really important question. In fact, 20% to 30% of all teens diagnosed with depression will go on to develop bipolar disorder. So parents of these teens should be especially vigilant for later signs of bipolar disorder.

CBS CARES: Do they know why these depressed teens go on to become bipolar?

DR. OQUENDO: It is currently not known why a depressed teen goes on to become bipolar or if there are early markers for the illness.

CBS CARES: And a depressed teen on an antidepressant alone may later need to be given mood stabilizers, too, if he or she subsequently develops bipolar disorder?

DR. OQUENDO: It is vital because, as I said earlier, antidepressants alone can make the manic aspects of bipolar disorder far worse.

CBS CARES: Are the children of bipolar parents more likely to be bipolar?

DR. OQUENDO: There does seem to be familial transmission of this disease, or inheritability of this disease. It's interesting. So, studies of children and adolescents, who have parents who have bipolar disorder, show that psychiatric symptoms occur in anywhere between twenty-four and ninety-two percent of the kids. Most of the studies find that the range is between forty and sixty percent. And of that forty and sixty percent, about a third of them can be expected to develop bipolar disorder. So that leaves you with anywhere between say thirteen and twenty percent.

CBS CARES: Do bipolar children of bipolar parents tend to get the condition at the same age as their parents or at a younger age?

DR. OQUENDO: There is a phenomenon called "genetic anticipation" in which subsequent generations have an onset of illness at an earlier and earlier age. I'm very concerned about this: the phenomenon has been shown in depression and it may also hold true for bipolar disorder.

CBS CARES: What signs should parents look for in terms of a child with possible bipolar condition? Obviously the mood swings, but what specific day-to-day activities or behavior of a young child or adolescent provide warning signs for parents?

DR. OQUENDO: Well, I think that the most reliable thing to observe has to do with sleep patterns. Sleep is sort of the lynch pin of mood stability. We know that the less you sleep, the more euphoric or manic you become. If you've ever had to work late into the night and not get very much sleep, you may have noticed that even though you're tired, you might feel giddy or elevated the next day. And you can imagine what that does in someone who has a predisposition towards mania or hypo-mania. So sleeping regularly and sleeping a serious six to eight hours a night is absolutely critical for adults, and for children it would be more, of course.

If you observe as a parent that your child seems to be sleeping much less then this, doesn't appear to be tired, and isn't having trouble waking up in the morning, then I would be concerned about looking for other symptoms of bipolarity. In addition, unusual behavior such as more pressured speech, meaning speaking much more quickly than usual, or being more active physically or in terms of creative projects would also be something that I would be alert to. Of course, the first presentation could be one of depression and not mania or hypomania.

It's worth saying that if these things are not a change from their usual, I would be a lot less concerned. We're looking at things that are changes in the usual things. So for example, for an adult who has only needed four to six hours of sleep their entire life, I would not pathologize them. But if somebody needs eight hours usually, and then all of a sudden is only sleeping two hours a day for days and days in a row, I think that would be more of concern.

CBS CARES: If a bipolar condition is suspected, what type of professional should parents have their child see?

DR. OQUENDO: I think it's absolutely critical to see a psychiatrist.

CBS CARES: What kind of a psychiatrist?

DR. OQUENDO: I would definitely recommend a psychiatrist who is familiar and comfortable with medication treatments. A child psychiatrist would be ideal. In contrast to depression, where there is evidence that some psychotherapies are useful in its treatment, in bipolar disorder to date, there is no evidence that psychotherapy alone is useful in the treatment of bipolar disorder.

CBS CARES: Would you say that bipolar disorder, as with depression, is usually treatable through medication?

DR. OQUENDO: It's very treatable.

CBS CARES: And people with bipolar disorder on the medication are capable of leading happy and high quality lives?


CBS CARES: What are the common side effects of the bipolar medications?

DR. OQUENDO: All medications, including aspirin, have side effects. And medications to treat bipolar conditions are no exception. In my experience, people often need to try a couple of things before they find something that's comfortable. And many times working with the doctor to find something that both controls the illness and is tolerable, in terms of the side effect profile, is an important part of the work that has to go on.

Side effects vary a lot from medication to medication, and there are very different classes. Things to look at are changes in weight, changes in appetite, changes in previous dermatologic conditions such as acne or eczema, changes in coordination, tremors, and difficulty concentrating. Some people feel somewhat dampened from the treatments, and they feel like they can't feel their feelings as intensely as they would like to. Nausea and frequency of urinations are others that are common.

CBS CARES: What percent of people with bipolar condition are comfortable enough on medications to continue taking them consistently over the long term?

DR. OQUENDO: I am not aware of any data on this. But, given the wide range of medicines available to treat bipolar disorder, it is unusual for any given individual not to be able to tolerate treatment.

CBS CARES: Are people with bipolar disorder especially difficult to convince about getting treatment? In the sense that grandiosity, for example, which accompanies the manic phase, could make them feel powerful, willful and manipulative?

DR. OQUENDO: I think that, during the manic and hypo-manic phase, it is almost always all but impossible to convince patients that they need treatment because they feel good for the most part. And that's where the family is instrumental. At times, hospitalization becomes necessary. In some cases, treatment has to occur against the person's will.

It's much different when the person is depressed. In the depressed phase, people are much more amenable because they're suffering terribly. In addition, I think one of the problems in treatment of bipolar disorder is that they often times have periods of time when they feel perfectly well. And also at those times they're vulnerable to stopping their own medications and risking relapse.

CBS CARES: It must be very hard from the therapist's perspective. So how do you deal with that?

DR. OQUENDO: Well, one of the best ways to do it is to try to have the family engaged, so that they can help bring about some pressure to have the person stick with their treatment. And often times, it's just after experience that people really understand that they need the treatment and that they have to go through a couple of cycles to see this.

We've also told the patients things like, "Let's write up a contract now that you're aware of your illness. There's going to be a time when you want stop the treatment, but you agree that you will continue to work with me on reasonable approaches to your condition." But that doesn't seem to work very well because often the insight just goes right out the window.

CBS CARES: How can alcohol or drug abuse interact with bipolar disorder and your ability to treat it effectively?

DR. OQUENDO: That's a great question. Alcohol and drug abuse are extremely common complications of bipolar disorder. And it's not well understood whether people use these substances to try to regulate their mood or manage their mood, or if the use of substances somehow makes the emergence of bipolar disorder more likely. However, the presence of substance abuse, and especially alcohol abuse, makes the treatment of bipolar disorder very, very difficult.

In particular, just as an example, when people are using a lot of alcohol, it disrupts sleep architecture. And as I mentioned before, sleep architecture or preserved sleep is a lynch pin to mood stability. So, if in addition to being manic or hypo-manic or depressed, you're also disrupting sleep by using alcohol, the ability to get the illness into a remission is going to be much more challenging.

CBS CARES: Well, that leads me to another question. Are some people with bipolar disorder also genetically predisposed to abuse drugs or alcohol and therefore especially difficult to help? Or are these people just self-medicating?

DR. OQUENDO: I don't believe we know the answer to that question yet, as a field.

CBS CARES: Is there research under way?

DR. OQUENDO: Certainly we are doing some research to try to understand that, looking at children of bipolar parents. But we're just collecting data now, so we don't have any answers yet.

CBS CARES: What has been the most dramatic recent development in the diagnosis and treatment of bipolar disorder? What do you know now which was not known, let's say, five or ten years ago?

DR. OQUENDO: Well, as I said before, we know that use of an antidepressant alone is dangerous. But, one of the things that we've learned recently is that use of an anti-depressant, together with a mood stabilizer, is perfectly safe in most bipolar disorder cases. This is extremely important because the depression is much harder to treat in general than the mania in bipolar disorder. It's with the depression that there's a risk of suicide or suicide attempt. So, we definitely want to be able to manage it aggressively. And for a period of about five to ten years, back in the '90s, psychiatrists were very worried about making patients worse by aggressively treating their depression.

CBS CARES: We read a statistic that ten percent of people with bipolar disorder eventually commit suicide. Are you familiar with that?


CBS CARES: Why is it so high, compared to depression alone? Bipolar suicide rates seem to compare with the mortality rate for many forms of cancer!

DR. OQUENDO: It's a very interesting question, and we're trying to understand it. It appears that at least one of the problems is the frequency with which patients with bipolar disorder become depressed. One of the things that's worth clarifying is that there's a lot of controversy about what the actual suicide rate is in bipolar disorder. So, you'll read anything between eight and nineteen percent.

The same is true for depression. You'll read anything between two percent and fifteen percent. And this depends on a variety of things. It depends on whether, for example, you're looking at mortality rates on people who are ill enough to need hospitalization, because then you'll see the higher rates. If you're looking at milder forms of the illness, the rates may not be as high. The suicidal behavior seems to correlate with the frequency of depressive episodes. Rapid cycling bipolar disorder appears to be especially associated with suicidal behavior. And anywhere between thirty and fifty percent of all patients with bipolar disorder, living in the community, will acknowledge having tried to kill themselves at least once.

CBS CARES: In depression, they track chemical changes that take place in the brain and other parts of the body. How do the chemical changes for bipolar patients differ from those of patients suffering from severe depression?

DR. OQUENDO: Well that's an excellent question, and what I can say is that there are a tremendous number of studies that look at biological changes in live patients with bipolar disorder. There are some post-mortem studies that have looked at brains of bipolar patients, but this field is really in its infancy, especially compared to depression, even though depression is in its infancy, too.

CBS CARES: What is the most exciting research at Columbia that's taking place on bipolar disorder?

DR. OQUENDO: You have to pick just one?!

CBS CARES: Well, what bipolar research at Columbia excites you the most?

DR. OQUENDO: We've opened a clinic to look at the offspring of bipolar parents and we're focusing on identifying early markers of bipolar disorder, be they clinical, genetic or neuro-biological. So, what we're studying these children, not only in terms of detailed psychiatric assessment, to see what their condition is now and follow them for a few years. But also we are doing functional magnetic resonance imaging to look at how their brain functions, for example when they're exposed to fearful faces or when they're confronted with a cognitive task that might be challenging. In addition, we will also be examining their parents to look at, for example, the interaction between parental substance abuse or alcohol abuse and the development of those particular conditions in the children as well.

CBS CARES: What ongoing training is there for psychiatrists who live away from major population centers to keep them abreast of bipolar diagnostic issues and developments?

DR. OQUENDO: An important one is through reading magazines and answering the quizzes after the articles to ensure that they in fact have learned something from the experience. But now there are also Internet based courses, and of course there are always conferences that offer training in the treatment and diagnosis of bipolar disorder. One key point is that for licensure, there now is a requirement for people to take specialty boards in psychiatry, I believe it's every 10 years, so that there is recertification to ensure that people's fund of knowledge stays up to date.

CBS CARES: What is the most common misperception about bipolar disorder and can you please clarify it for readers of this interview?

DR. OQUENDO: I think the most common misperception is that the most difficult part of dealing with a bipolar disorder has to do with manic or hypo-manic episodes. Those are certainly extremely disruptive, but in general they tend to be less common, and we have much more effective treatments than for the depression. The depression tends to be more difficult to treat, and is associated with terrible morbidity and of course mortality from suicide.

CBS CARES: What is the most important piece of advice you can give to someone who suffers from bipolar disorder and to their loved ones?

DR. OQUENDO: I would say that aiming for mood stability at all costs. For example, sticking with the treatment and working with the doctor to find a medication or a combination of medications that works and is tolerable is absolutely key. Early identification of emerging symptoms also can prevent worsening.

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