in Treating Bipolar
Disorder
Suryo Dharmono
Department of Psychiatry, Faculty
of Medicine, University of Indonesia
Ilustrasi Kasus
Tn S, 35 tahun, Wiraswasta, tidak
menikah
Ditegakkan diagnosis MDD episode
berulang sejak 4 tahun yang lalu
Riwayat tidak patuh berobat, hampir
setiap tahun mengalami kekambuhan
Setiap kali kambuh respons terhadap
obat antidepresan sangat baik,
pemberian sertraline 50mg per hari
remisi gejala dalam waktu kurang dari 2
minggu pasien menghentikan obat
Questions .
Treatment Resistant
Depression ?
Mall-Treatment ?
Miss-Diagnosis ?
What should we do ?
Self Awareness'
10 status dengan diagnosis akhir
Gangguan Bipolar , dilakukan kajian
terhadap stabilitas diagnosis pada
evaluasi awal:
- 3 status pernah didiagnosis depresi berat
- 2 status pernah didiagnosis skizofrenia
- 1 status pernah didiagnosis skizoafektif
- 1 status pernah diagnosis anxietas panik
- Hanya 3 status yang di diagnosis bipolar
dari sejak awal
Miss-Diagnosis Bipolar
Base on Initial Assessments
60%
60
Depresion
Persentasi (%)
50
Anxiety
40
30
Schizophrenia
26%
18% 17%
20
10
14%
Borderline personality
Alkohol Abuse
0
NDMDA = National Depressive and Manic-Depressive Association; N = 400
Hirschfeld RM, et al. J Clin Psychiatry. 2004;65(suppl 15):5-9.
Think Bipolar
When..
Think Bipolar
When
Treatment resistant to
antidepressants
Antidepressants cause
agitation,irritability
Perugi, Toni, et al., 2003
Think Bipolar
When
History of + response to
antidepressants, but
loss of efficacy after
a month or two
Think Bipolar
When?
Clear Seasonal Pattern
MDD with racing
thoughts
Think Bipolar
When?
Psychotic Symptoms
Frequent recurrence
more than one a year
.almost 100%
Atypical Symptoms of
Depression
Treatment challenges in
bipolar disorder
Initial diagnosis
Comorbidities
Depression
Chronic disorder
Phenotypes
Evans. J Clin Psychiatry 2000; Hirschfeld et al. J Clin Psychiatry 2003; Judd et al. Arch Gen Psychiatry 2002;
Judd et al. J Affect Disord 2003; Citrome & Goldberg. Postgrad Med 2005; Kupka et al. Bipolar Disord 2007
Objectives of treatment
Functionalit
y
Remission
Improvement
n=34
n=79
Remission sustained
8 weeks
(35%)
n=40
Remission sustained
1 year
(19%)
n=22
Percentage of patients
64%
34
%
Clinical remission:
6 months
asymptomatic
Functional recovery:
clinical remission
+ good social
function
(work, independence, social
activities and relationships)
Haro et al; EMBLEM Advisory Board. Eur
Neuropsychopharmacol 2011
Relapse prevention
Insight
Subsyndromal
symptom control
Personal autonomy
Improved
functioning
Physical health
Sleep
Cognition
Improvements in all
dimensions of bipolar
disorder are extremely
important for improving
quality of life
Three Phases of
Treatment
Episode
0-2 months
Symptomatic
Continuation
2-12 months
Functional
Maintenance
Indefinite
Stability/adaptive
Anticonvulsants
No class effect in severe mania
Tolerability problems
Drug interactions
Antidepressants
May exacerbate or even promote mania symptoms
Maintenance
Acute Depression
Year Drug
Year Drug
Year Drug
1970 Lithium
1974 Lithium
1973 Chlorpromazine
2003 Lamotrigine
1994 Divalproex
2004 Olanzapine
2003 Olanzapinefluoxetine
combination
2000 Olanzapine*
2005 Aripiprazole
2006 Quetiapine
2003 Risperidone*
2004 Quetiapine*
2004 Ziprasidone
2004 Aripiprazole
2004 Carbamazepine
Mixed
Psychotic
Rapid
Cycling
Olanzapine1,2
Risperidone3,
Quetiapine5,p
Ziprasidone6,
Aripiprazole7,
p
Tohen M, et al. Am J Psychiatry 1999;156:702-9; 2Tohen M, et al. Arch Gen Psychiatry 2000;57:841-9;
3
Sachs G et al. Am J Psychiatry. 2002;159:1146-1154; 4Hirschfeld RM, et al. Am J Psychiatry
2004;161:1057-65; 5Yatham LN, et al. J Clin Psychopharmacol 2004;24:599-606; 6Potkin SG, et al. 157th
APA Ann Mtg, New York, May 1-6, 2004; 7Jody D, et al. 157th APA Ann Mtg. New York, NY, May 1-6, 2004. p
1
Manic
Mixed
Maintenance
Depression
Lithium
Lithium
Divalproex
Divalproex DR
DR
Divalproex
Divalproex ER
ER
Carbamazepine
Carbamazepine ER
ER
MOOD
MOOD STABILiseR
STABILISER
ANTYPICALS
ATYPICALS
Risperidone
Risperidone
Olanzapine
Quetiapine
Ziprasidone
Aripiprazole
Aripiprazole
Lamotrigine
Olanzapine/fluoxetine
OTHER
AMAZE STUDY
ARIPIPRAZOLE EFFECTIVE TO IMPROVE
SYMPTOMS IN
BIPOLAR DISORDERS
Aripiprazole
0
N = 107 112
15
13
N = 44 45
78
80
10
12
14
12
14
Manic
Mixed
(aripiprazole vs placebo)
manic 28.2 vs 28.2
Mixed 28.9 vs 26.5
16
112 112
10
12
N = 10 13
10
16
Placebo
14
With
Without
psychot psychotic
ic
symptoms
sympto
(Aripiprazole
vs placebo)
ms
With
30.3 vs 30.0
Without 27.2 vs 26.9
16
Rapid cyclingNon-rapid
cycling
(Aripiprazole vs placebo)
rapid 32.7 vs 28.2
Non-rapid 27.9 vs 28.0
Percent of Patients
50
Superior
Episode
Prevention
43%
Equivalent
Depression
Prevention
Equivalent
Mixed
Prevention
Superior
Mania
Prevention
40
p=.013
30
25%
20
p=.009
12% 13%
10
0
5%
Overall
Relapse
23%
Placebo (n=83)
Relapse into
Depression
6%
Relapse into
Mixed
8%
Relapse into
Mania
Stabilized on open ARI before randomization (mean 12.7 weeks). Relapse criteria - hospitalized or medication added.
Keck PE, et al. J Clin Psychiatry 2006;67:626-37.
akathisia
insomunia
tremor
vomiting
nausea
constipation
diarrhoea
salivary hypersecretion
blood CPK increased
headache
1-4 5-7
8-10
11-14
15-28
endpoint*
(ng/mL)
Weight Gain
Diabetes Risk
Dyslipidem
Clozapine
+++
Olanzapine
+++
Risperidone
++
Quetiapine
++
Aripiprazole
+/-
Ziprasidone
+/-
Conclusion
Bipolar disorder is a chronic,
Under-recognition and
Lanjutan Kasus
Pasien menjalani rawat inap selama 4
minggu
Antidepresan dihentikan
Aripiprazole 15mg + Na Divalproat
500mg minggu ke 3 perawatan
gejala remisi minggu ke 4 pasien
dipulangkan
Diagnosis pulang Gangguan Bipolar
Episode kini campuran
Waiting a miracle
occur..???
Sometimes questions
are more important than answers
- David Baird-