Source: Shastry 2005; Pini 2005; Hirschfeld 2003; Goodwin and Jamison 1990; Evans 2000; Murray 1997; Woods 2000 3
32% 53%
n = 146; 12.8-year follow-up
Banyak pasien tidak merasakan adanya manfaat dari penggunaan mood stabiliser ini dalam periode jangka panjang
Eduard Vieta
Perubahan perasaan ini atau disebut episode dapat bertahan selama beberapa jam, hari, minggu atau bahkan beberapa bulan.
Berdasarkan kriteria diagnosa, ada beberapa tipe gangguan bipolar yaitu: Gangguan bipolar tipe I Gangguan bipolar tipe II
Cyclothymia
Gangguan bipolar tidak spesifik (NOS)
Source: Shastry 2005; Pini 2005; Hirschfield 2003; American Psychiatric Association 2000; Murray 1997; Evans 2003; Goodwin 1990
Mania
Maintenance
Subsyndromal Depression (Dysthymia)
Depression
Cyclothymia
Beberapa periode hipomanik dan gejala depresi selama 2 tahun (tidak pernah episode depresi mayor atau episode manik)
Diagnosa
Adanya tanda-tanda utama dan gejala-gejala yang khas yaitu manik dan depresi Diagnosa memerlukan waktu hingga 10 tahun Kesalahan diagnosa umum terjadi 1 dari 3 pasien pernah mengalami kesalahan diagnosa dan sebelumnya datang ke 4 dokter sebelum diagnosanya ditegakkan secara benar
Source: Hirschfield 2003; Evans 2000 10
11
20%
49% 31%
Tidak didiagnosa secara benar, melainkan sebagai depresi saja
13
Persentasi (%)
50 Cemas 40
26%
30 20
Skizofrenia
18% 17%
14%
10 0
NDMDA = National Depressive and Manic-Depressive Association; N = 400
14
BIPOLAR DISORDER
Psychotic Symptoms
Delusions Hallucinations
Slide courtesy of Keck PE Jr.; adapted from Goodwin FK, Jamison KR. Manic-Depressive Illness. Oxford University Press: New York, NY; 1990.
16
Cognitive
Racing thoughts Distractibility Poor insight Disorganization
Physical
Rapid or pressured speech Increased energy Decreased need for sleep Increased libido Overly active, social, or hostile behavior Recklessness, bizarre behavior, destruction of property Sleep and endocrine abnormalities
Impaired attention
Impaired comprehension
Dysphoric/Mixed Mania
Depression/Anxiety co-mixed Irritability Hostility or violence
Psychotic
Delusions Hallucinations
Sensory hyperactivity
Ciri-ciri Hipomanik
Hipomanik merupakan komponen penting dari gangguan bipolar tipe II dan gangguan cyclothymic Suatu periode berbeda dari perasaan yang naik, ekspansif, atau mudah tersinggung, yang bertahan selama 4 hari Selama periode munculnya gangguan perasaan tadi, setidaknya 3 dari gejala manik akan tetap ada dan menonjol
Cognitive
Poor self-esteem Poor concentration
Physical
Change in:
Sleep
Endocrine function Appetite and/or weight Activity Energy Slow thought and
Indecisiveness
Suicidal ideas Self-blame
speech
Source: American Psychiatric Association 2000 20
Depresi 67%
Depresi 93%
21
Sekilas tentang dampak personal dan sosial ekonomi dari gangguan bipolar
Salah satu yang menyebabkan ketidakmampuan mengerjakan sesuatu (disability) Memiliki dampak ekonomi yang tinggi Berdampak pada pekerjaan individu dan hubungan sosial yang serius Dikaitkan dengan stigma sosial Adanya risiko bunuh diri
Source: Shastry 2005; Pini 2005; Murray 1997; Woods 2000; Wyatt 1995; Begley 2001; Gupta 2002; World Federation of Mental Health 2005; Sachs 2003 23
24
Ketidakmampuan
7th
Akibat Perang
Memiliki risiko tinggi penyakit kardiovaskular dan kanker Memiliki dampak ekonomi yang tinggi ($45.2 milyar di USA pada tahun 1991)
8th
Akibat Kebrutalan
9th
Skizofrenia
Wyatt and Henter 1995; Murray and Lopez 1997; Woods 2000; Murray 1996; Dion 1988
25
Pasien dengan riwayat percobaan bunuh diri mengalami perjalanan penyakit yang lebih kompleks dan lebih berat
Source: Tondo, et al. 2003; Jamison 2000; Leverich, et al. 2003 26
27
28
Pulih
Periode dimana remisi dipertahankan
Kambuh
Gejala yang kembali muncul sama dengan fase remisi
Ulangan
Perulangan suatu episode
30
Antipsikotik atipik
Aripiprazole Clozapine Olanzapine Quetiapine Risperidone Ziprasidone
Antidepresan
Antipsikotik tipik
Haloperidol Chlorpromazine Thiothixine
Note: Some of these agents are not approved for treatment of bipolar disorder
31
Manic Manic
+
+ + +
Mixed Mixed
+ +
Maintenance Maintenance
+
Depression
Lithium Lithium
Divalproex DR Divalproex DR Divalproex ER Divalproex ER Carbamazepine ER Carbamazepine ER ANTYPICALS ATYPICALS Risperidone Risperidone Olanzapine Olanzapine Quetiapine Quetiapine Ziprasidone Ziprasidone Aripiprazole Aripiprazole OTHER OTHER Lamotrigine Lamotrigine Olanzapine/fluoxetine Olanzapine/fluoxetine
+
+ + + +
+
+ + +
+ +
+ +
Drugs listed in order of approval for a bipolar disorder indication. This chart does not imply comparable efficacy or tolerability profiles. Physicians Desk Reference. 60th ed. Montvale, NJ: Medical Economics Co; 2006
32
Options Treatments
First-line
Lithium, divalproex, olanzapine,, quetiapine monotherapy, risperidone aripiprazole, ziprasidone, lithium or divalproex + risperidone, lithium or divalproex + quetiapine, lithium or divalproex + olanzapine Carbamazepine, oxcarbazepine, ECT, lithium + divalproex Haloperidol, chlorpromazine, lithium or divalproex + haloperidol, lithium + carbamazepine, clozapine Monotherapy with gabapentin, topiramate, lamotrigine, verapamil, tiagabine, risperidone + carbamazepine
Second-line Third-line
Not recommended
Yatham LN, et.al., Canadian Network for Mood and Anxiety Treatments (CANMAT) guidelines for the management of patients with bipolar disorder: update 2007, Bipolar Disorders 2006: 8: 721739
33
Options Treatments
First-line
Lithium, lamotrigine, lithium or divalproex + SSRI, olanzapine + SSRI, lithium + divalproex, lithium or divalproex + bupropion,
Quetiapine monotherapy*
Second-line Third-line
Not recommended
*) Disclaimer: indication of bipolar depression is under evaluation by BPOM and has not been approved
Yatham LN, et.al., Canadian Network for Mood and Anxiety Treatments (CANMAT) guidelines for the management of patients with bipolar disorder: update 2007, Bipolar Disorders 2006: 8: 721739
34
35