Tuesday, 1 May 2018

Bipolar And Unipolar Disorder: Co-morbidity, Prognosis, Factors And Treatment

The Co-morbidity is common for both Polar and Unipolar disorders. Some common co-morbid psychiatric disorders include Anxiety disorder, alcohol/substance misuse, personality disorders, eating disorders, ADHD. 

Whereas, Physical co-morbidities include: Thyroid dysfunction, migraine, metabolic syndrome (induced by antipsychotics).
Bipolar and unipolar depression :Signs and Symptoms and treatment


Prognosis Of Mood Disorders- Poor Prognostic Factors

  •  Earlier age of onset(childhood-onset Bipolar).

  • Longer duration/increased severity of episodes.

  • Poor initial response to treatment.

  • Suicidal behavior.

  • Alcohol and substance misuse.

  • Low level of social support/ social integration.

Additionally increased frequency of episodes, Psychotic symptoms, mixed episodes, family factors such as high expressed emotions, and the first episode of depression rather than Mania are some poor prognostic factors for the Bipolar disorder.



Treatment of Depression (Bipolar And Unipolar Disorder)-



There are two main treatment approaches for depression, which is  used either on their own or in combination:
  1. Anti-depressants

  1. Psychotherapy (usually CBT-Cognitive Behaviour Therapy)

Rationale For Anti- Depressants-

Monoamine Hypothesis of Depression: This states that depression is due to a deficiency of Monoamines(Serotonin or Noradrenaline) in the brain so, by increasing the levels of one or both of these monoamines, depression can be treated.


Newer Antidepressant :

1) Agomelatine:
  • Agonist at MT1/MT2 melatonin receptors.
  • Melatonin, secreted by the pineal gland (which is important to sleep).
  • MT1 and MT2 receptors are located in the suprachiasmatic nucleus of the hypothalamus(the sleep center).
  • Common side effects include diarrhea, headache, and nausea.


General Principles When using Antidepressants.

  • Start Low, Go Slow

    •          Start at a low dose.

    •          Increase dose gradually(if needed).

    • Review mental state regularly.

    • Monitor for side effects.

    • Avoid 'poly-pharmacy'(using more than one antidepressant, except for treatment-resistant Depression)

NOTE- It usually takes at least 2 to 3 weeks for an anti-depressant effect to manifest. If the patient improves, continue medication for several months after recovery. 


If the patient doesn't improve, gradually change to the other anti-depressant. If repeated relapses, consider long-term maintenance treatment.


COGNITIVE BEHAVIOR THEORY (CBT)

The aim of CBT is to help the patient'to correct the negative cognitions and other unhelpful behaviors that maintain the depression because of negative cognitions and maladaptive behaviors can cause one to feel low in mood and which leads to depression.


Management Of Bipolar Depression-
  • Among atypicals: Quetiapine may be the drug of choice.

  • Among anti-epileptics: Lamotrigine may be the drug of choice.

  • For severe, treatment-resistant depression: ECT may be an option.

General Management Principles

  • Assess suicidal risk during depressive/mixed episodes.

  • Assess safety issues(to the patient and others as well) during manic episodes.

  • Identify and try to address contributory factors such as work stressors, physical health issues, alcohol misuse, etc.

  • Educate the patient about the illness and rationale of treatment.

  • Advice patients about Sleep Hygiene as disturbed sleep is a prominent risk factor for relapse and also for switching from Depression to Mania.

Long-term course of Bipolar Disorder-
    
  • The average duration of a Depressive episode is (months) is more than that of Manic episodes.

  • Women with the Bipolar disorder may experience more Depressive episodes than men with Bipolar disorder.

  • Patients with Bipolar disorder tends to have more and longer Depressive episodes in the course of their lifetime than patients with the Unipolar disorder.

  • On an average, a Bipolar patient will experience about 10 episodes in their lifetime with a roughly equal number of depressive/manic episodes.




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