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Bipolar Disorders Masterclass Netwerk Vroege Psychoase Utrecht, 10 Februari 2017 Disclosure Ralph Kupka

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Bipolar Disorders Masterclass Netwerk Vroege Psychoase Utrecht, 10 Februari 2017 Disclosure Ralph Kupka Early recognition of bipolar spectrum disorders Ralph Kupka, MD PhD Professor of Bipolar Disorders Masterclass Netwerk Vroege Psychoase Utrecht, 10 februari 2017 Disclosure Ralph Kupka Over the past 5 years, I have an interest in relation with one or more organisations that could be perceived as a possible conflict of interest in the context of the subject of this presentation. The relationships are summarised below: Interest Name of organisation Grant NWO Advisory boards n/a Share holder n/a Other involvement • Honoraria for lectures on symposia sponsored by AstraZeneca, Bristol-Myers Squibb, Eli Lilly, Janssen, Lundbeck • Royalties from UpToDate, De Tijdstroom Bipolar basics Age of onset of bipolar disorder Staging models for bipolar disorder Is there a bipolar prodrome? Early intervention in bipolar disorder Some conclusions Bipolar basics Age of onset of bipolar disorder Staging models for bipolar disorder Is there a bipolar prodrome? Early intervention in bipolar disorder Some conclusions Mood pathology • depressed mood • no energy / drive / pleasure • feeling useless and worthless • no initiative Depression • can not sleep suicide • suicidal ideas / behavior Mood pathology • euphoric/irritable mood Mania • increased activity / energy • feeling great severe • reckless behavior • need not sleep Hypomania damage • no insight Mood pathology • euphoric/irritable mood Mania • increased activity / energy • feeling great severe • reckless behavior • need not sleep Hypomania damage • no insight • depressed mood • no energy / drive / pleasure • feeling useless and worthless • no initiative Depression • can not sleep suicide • suicidal ideas / behavior Mania and Melancholia through the ages Hippocrates Aretaeus of Robert Herman of Kos Cappadocia Burton Boerhaave Francois Jean-Pierre Karl Emil Karl Jules Baillarger Falret Kahlbaum Kraepelin Leonhard Angst Manic-depressive illness is separated from dementia praecox (schizophrenia) Bipolar disorder is separated from unipolar depression Karl Leonhard Jules Angst George Winokur (Ger, 1957) (CH, 1966) (USA, 1969) The debate goes on Young & MacQueen, 1999 The problem of defining hypomania Goodwin, 2002 Prevalence of major depressive disorder versus bipolar spectrum disorder (Angst et al, 2003) Angst et al (2003) Eur.Neuropsychopharmacology DSM-5 mixed features specifier Manic episode, with mixed features Bipolar disorder Hypomanic episode, with mixed features Major depressive episode, with mixed features Major depressive disorder, Bipolar disorder, if no lifetime mania / hypomania if lifetime mania / hypomania Bipolar Disorder: single and biphasic episodes NIMH-LifeCharts® from the Stanley Foundation Bipolar Network Patient a Patient b Patient c Patient d Patient e 1 year Bipolar Disorder: rapid cycling and mixed episodes NIMH-LifeCharts® from the Stanley Foundation Bipolar Network Patient f Patient g Patient h 1 year Bipolar disorder has a heterogenous longitudinal course Patient 1 Patient 2 Patient 3 Patient 4 5 years Bipolar basics Age of onset of bipolar disorder Staging models for bipolar disorder Is there a bipolar prodrome? Early intervention in bipolar disorder Some conclusions Age at onset of bipolar disorder (data from 7 studies including N=2968 patients; Goodwin & Jamison 2007) Age at onset of bipolar disorder Stanley Foundation Bipolar Network N = 539 Age range 18 - 82 Mean age 42.5 (SD 11.5) Data from 7 studies including N=2968 patients Mean age of onset 23.4 (SD = 10.7) (Goodwin & Jamison 2007) Retrospective assessments Age at first symptoms (N=495 BP I and BP II) (Stanley Foundation Bipolar Network) Depression first Depression and 80 (hypo)mania at N= 267 (53%) same age 70 N= 156 (32%) 60 50 40 30 20 (hypo)mania first 10 N= 72 (15%) age (hypo)manic symptoms first 0 0 10 20 30 40 50 60 70 age first depressive symptoms Retrospective assessments Bipolar basics Age of onset of bipolar disorder Staging models for bipolar disorder Is there a bipolar prodrome? Early intervention in bipolar disorder Some conclusions Scott et al Br J Psychiatry, 2013 McGorry et al. Can J Psychiatry, 2010 Long-term staging of bipolar disorder (Berk et al, Bipolar Disorders, 2007; 9: 671- 678) Three models for staging of bipolar disorder Berk et al, 2007 pro at risk dro Focus on recurrence of episodes mal First Stage 0 episode recurrent bipolar 1a/b chronic/ 2 resistant 3a 3b 3c Age of onset 4 (Berk et al, Bipolar Disorders, 2007; 9: 671- 678) Duffy, 2014 Focus on prodromal / early stages Kapczinski et al, 2010 Focus on functional impairment/ later stages Long-term staging of bipolar disorder (Berk et al, Bipolar Disorders, 2007; 9: 671- 678) Stage 0 Stage 1 Stage 2 Stage 3 Stage 4 UHR , specific - Prodromal Mild, non Mild, pro at risk dro mal First Stage 0 episode recurrent bipolar 1a/b chronic/ 2 resistant 3a 3b 3c Age of onset 4 Time Illness progression LongNo problem-term ifstaging bipolar disorder of bipolar starts withdisorder mania (Berk et Diagnosisal, Bipolar Disorders, 2007; 9: 671- 678) Bipolar disorder pro at risk dro mal First Stage 0 episode recurrent bipolar 1a/b chronic/ 2 resistant 3a 3b 3c Age of onset 4 (Berk et al, Bipolar Disorders, 2007; 9: 671- 678) HowLong to deal-term with staging first depression(s) of bipolarin bipolar disorder disorder? (BerkUnipolar et al, BipolarDiagnosis Disorders, 2007; 9: 671- 678) or Bipolar Bipolar disorder disorder?? pro at risk dro mal First Stage 0 episode recurrent bipolar 1a/b chronic/ 2 resistant 3a 3b 3c Age of onset 4 (Berk et al, Bipolar Disorders, 2007; 9: 671- 678) Proposal for staging of bipolar disorder (modified from Berk et al, Bipolar Disorders, 2007; 9: 671- 678) Unipolar Diagnosis Interepisodic depression Bipolar impairment disorder (Rapid) cycling Full recovery Bipolar I recurrent Bipolar II XXX at risk prodromal (hypo-) Stage 0 mania chronic/ recurrent bipolar 1a 1b 1c 1d resistant/ 2 cycling 3a 3b 3c Age of onset 4 Kupka & Hillegers, Tijdschrift voor Psychiatrie, 2012 (further modified 2015/2016) Age at first mood symptoms (N=495 BP I and BP II) (Stanley Foundation Bipolar Network) Depressive symptoms Depressive and first 80 manic symptoms N= 267 (54%) at same age 70 N= 156 (32%) 60 50 40 30 20 Manic symptoms first 10 N= 72 (15%) age (hypo)manic symptoms first 0 0 10 20 30 40 50 60 70 age first depressive symptoms Retrospective assessments Retrospective and prospective course of illness NIMH-LifeCharts from the Stanley Foundation Bipolar Network (1995-2002) Depression at onset age 20 first depression 1984 - 1989 age 23 first mania 1990 - 1995 500-007: female, born 1967; negative first degree family history of bipolar disorder SFBN-NFS study entry: october 1995 Retrospective and prospective course of illness NIMH-LifeCharts from the Stanley Foundation Bipolar Network (1995-2002) Mania at onset age 26 1972 - 1977 1978 - 1983 1984 - 1989 1990 - 1995 500-011: male, born 1949; negative first degree family history of bipolar disorder SFBN-NFS study entry: december 1995 Stage 2: first diagnosis of bipolar disorder SFBN/NL, N=98 BP-I, retrospective LifeCharts Duffy. Can J Psychiatry, 2014 Duffy. Can J Psychiatry, 2014 Kapczinski’s model for staging of bipolar disorder Kapczinski et al, 2010 Focus on functional impairment Stage Emphasis on interepisodic functioning 0 Increased risc, only mild symptoms I Euthymic between episodes, return to premorbid functioning II Psychiatric symptoms between episodes III Marked cognitive and functional impairment between episodes IV Unable to function independently due to severe cognitive and functional impairment Bipolar basics Age of onset of bipolar disorder Staging models for bipolar disorder Is there a bipolar prodrome? Early intervention in bipolar disorder Some conclusions Dutch Bipolar Offspring Study (Nolen, Reichart, Hillegers, Wals, Mesman, et al) Development of psychopathology in bipolar offspring (N=140) (Dutch Bipolar Offspring Study, Mesman & Hillegers et al, Am J Psych 2013) 12-21 year 22-32 year Development of psychopathology in bipolar offspring (N=140) (Dutch Bipolar Offspring Study; Mesman & Hillegers et al, in press) Subthreshold manic symptoms predict conversion from depression to bipolar disorder Bipolar basics Age of onset of bipolar disorder Staging models for bipolar disorder Is there a bipolar prodrome? Early intervention in bipolar disorder Some conclusions How early is an early intervention? asymptomatic at risk? aspecific symptoms? specific symptoms (UHR)? first depression? first mania? early recurrent? Berk et al. Bipolar Disorders 2007 Bipolar basics Age of onset of bipolar disorder Staging models for bipolar disorder Is there a bipolar prodrome? Early intervention in bipolar disorder Some conclusions The boundaries of bipolar disorder are still open Subsyndromal manic symptoms define the prodrome for bipolar disorder Balancing early detection versus overdiagnosing mental illness in ‘high-risk’groups ? + - Amelioration of symptoms Labelling Minimizing disability and Stigma cognitive impairment Side-effects of interventions Preventing illness progression Ratheesh et al. Early Interv Psychiatry 2016 Thank you for your attention.
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