Bipolar affective disorder
Bipolar affective disorder (abdominal BAR, previously - manic-depressive psychosis, MIS, originally - circular psychosis) - endogenous mental disorder manifested in the form of affective states - manic (or hypomaniacal) and depressive, and sometimes mixed. conditions, in which the patient has a rapid change in the symptoms of mania (hypomania) and depression, or symptoms of depression and mania at the same time (for example, depression with excitement, anxiety or euphoria with retardation - the so-called nep or a different form of mania).
Multiple variants of "mixed" states are possible.
These conditions, called episodes or phases of the disease, periodically change each other, directly or through the "light" intervals of mental health (intermissions, called interphases), without or almost without a reduction in mental functions, even with a large number of transferred phases and any duration of the disease. In interferences, the psyche and personality properties of the patient are fully restored .6.. It should be noted, however, that patients with bipolar disorder often (approximately 75% of cases) suffer from other, concomitant, mental disorders (this may be, for example, an anxiety disorder).
In the American classification of mental disorders, DSM-5 is called Bipolar I Disorder and Bipolar II Disorder. The second type is characterized by the presence of only hypomaniacal and depressive episodes.
Treatment of BAP is a complex task, as it requires a detailed understanding of psychopharmacology. Patients with bipolar disorder usually take a lot of potent drugs (many patients with six or more drugs at the same time), which makes it difficult to account for the drug interaction and to prevent side effects.
- 1 Historical Background
- 2 Classification
- 2.1 Varieties of bipolar disorder
- 2.2 The concept of the bipolar spectrum
- 3 Prevalence
- 4 Etiology and pathogenesis
- 4.1 Genetic factors
- 4.2 Risk factors
- 4.2.1 Characteristics of the personality
- 5 Clinical picture, course
- 5.1. The course of the manic phase
- 5.2. The course of the depressive phase
- 5.2.1 Variations of the course of the depressive phase
- 5.3 Mixed states
- 5.4 Fast Loops
- 6 Diagnostics
- 6.1 Differential diagnosis
- 7 Treatment
- 7.1 Pharmacotherapy
- 7.1.1 The Depressive Phase
- 7.1.2 The Manic Phase
- 7.1.3 Fast Loops
- 7.1.4 Prevention of exacerbations of BAP
- 7.2 Psychotherapy
- 7.3 Other treatments
- 8 Forecast and Expertise
- 9 See also
- 10 Notes
- 11 References
- 12 References
Emil Krepelin, (1856-1926), in 1896, he proposed the term "manic-depressive psychosis".
For the first time as an independent disease, bipolar disorder was described in 1854 almost simultaneously by two French researchers J.P. Falre (English), Russian, under the name "la folie circulaire" (la f?li si?.ky.l??) , and Zh. G. F. Bayrij (English), Russian, under the name "insanity in two forms". However, for almost half a century, the existence of this disorder was not recognized by the psychiatry of that time and due to its definitive isolation into a separate nosological unit is due to the German psychiatrist E. Krepelin (1896). Krepelin introduced for him the name manic-depressive psychosis (MDP), which for a long time was generally accepted, but with the entry into force in 1993 of the ICD-10 classifier, it is considered not entirely correct, because this disease is not always accompanied by psychotic disorders, and not always with it there are both types of phases (both mania and depression). In addition, the term "manic-depressive psychosis" is to a certain extent stigmatizing with respect to patients. Currently, the disease is accepted in the US and recommended by WHO more scientifically and politically correct name "bipolar affective disorder", abbreviated BAP. This naming is also not completely correct and leads, for example, to a terminology such as the "monopolar form of bipolar disorder".
Until now, in psychiatry there is no single definition and understanding of the boundaries of this disorder, which is associated with its clinical, pathogenetic and even nosological heterogeneity.
From the clinical and prognostic points of view, the most preferable is the classification of bipolar disorder, depending on the prevalence of a pole of manic-depressive symptoms: unipolar variants (manic or depressive), bipolar with predominance of (hypo) manic or depressive phases, and clearly bipolar, with an approximate equality of phases.
The following variants of the BAR.4 current can be distinguished:
- periodic mania - alternate only manic phases;
- periodic depression - alternate only depressive phases; syndromal classifiers ICD-10 and DSM-IV classify this variant as recurrent depression, although this allocation may not be justified nosologically;
- correctly-alternating type of flow - through "light" intervals, intermissions, manic phase replaces depressive, and depressive - maniacal;
- incorrectly intermittent flow type - through "light" intervals manic and depressive phases alternate without strict sequence (after the manic phase maniacal can start again and vice versa);
- the double form is the direct replacement of two opposite phases, after which the interphase follows;
- the circular type of the current (Latin psychosis circularis continua C. C. Korsakov) - with the "correct" alternation of phases there are no interferences.
The most frequent is the periodic (or intermittent) type of the course of affective psychosis, when the affective phases are correctly intermittent.The relatively regular alternation of periods of the disease (affective phases) and intermissions is a characteristic feature of this type of bipolar psychosis current - its circularity called the circular form by J. Falre (English) Russian). Even more common is periodic depression.18., ICD-10 refers to another category (F33).
The concept of the bipolar spectrum
Large-scale studies of recent years have made it possible to put forward a hypothesis of a wide range of bipolar disorders. According to this concept, bipolar spectrum disorders account for up to 50% of all mood disorders - an opinion that contradicts the widespread view that at least 80% of affective disorders are recurrent depression and dysthymia.
For example, the bipolar spectrum of H. Akiskal (1983), J. Klerman (1987) includes, in addition to BAP I and BAP II, type III BAP (cyclotomy), type IV BAR (repeated episodes of depression and antidepressant hypomania) and depression in hypertensive temperament. It is also proposed to distinguish as separate types of BAR recurrent depression, accompanied by symptoms of dysphoric hypomania, and late manifestation of depression with features of mixedness, flowing into a syndrome resembling dementia.
The difficulty in accurately assessing the prevalence of bipolar disorder is associated not only with the variety of criteria (in the "broad" approach, the proportion of people suffering from it is up to 7%, while for "conservative" it is less than 0.05% .22.), But and with the inevitable subjectivity of diagnosis in psychiatry.
According to foreign studies, the prevalence is between 0.5 and 0.8% (5-8 people per 1000), and according to data obtained from the study of patients in the HDPE (1982, Moscow), the proportion of patients with bipolar disorder was 0.045%. (0.45 per 1000 population, out of them ? were treated mainly out-patient, and psychotic forms of the disorder were observed only in ?). Men and women, as well as representatives of various cultural and ethnic groups, suffer from bipolar disorder equally often.
The likelihood of having a "classical" bipolar disorder during the course of one's life (with at least one manic episode) is estimated at 2% .26., And without taking into account the form of the disorder, 4%.
There is no precise data on childhood morbidity since the applicability of criteria for diagnosis in adults is limited.The general prevalence of depression (of all varieties) in adolescence ranges from 15 to 40%. Many studies emphasize that the greater prevalence of affective disorders in adolescence corresponds to a greater incidence of suicide.
The distribution of the debut of the disease by age shows that at the age of 25-44 years 46.5% fall ill, that is, about half of all BAP patients.31 Bipolar forms more often develop at a younger age, up to 25 years, and unipolar forms - after 30 years.
Accumulation of data on morbidity in the families of patients, especially among monozygotic twins allowed to establish a quantitative relationship of genetic and environmental factors in the development of bipolar disorder. Studies have shown. That the contribution of genetic factors was 70%, and environmental - 30%. At the same time, the contribution of random environmental factors was 8%, and the share of general households - 22%. In later (1989) foreign studies, the contribution of genetic factors was estimated to be 80%, and casual environmental factors - 7%, which closely corresponds to the previous data.
The nature of the inheritance of a predisposition to a disease (one or more genes, or involving phenocopy mechanisms, etc.) is still not clear.36 Although there is evidence in favor of disease transmission by a single dominant gene with incomplete penetration, linked to the X-chromosome. Which is especially characteristic of bipolar psychoses, in contrast to unipolar ones. The same cohesion can explain the coupled inheritance of MDP and color blindness, which is considered even as a genetic marker of affective disorders. In addition, the genetic markers include the deficiency of the enzyme glucose-6-phosphate dehydrogenase (G6PO).
In the process of genetic mapping studies based on genome scanning in family members with patients, results were obtained that indicated the different locations of the corresponding genes (in particular, the pericentromeric region of the chromosome of the 18th chromosome.39, the locus q22.3 of the 21st chromosome.40., or at the locus q23.41 of the 18th chromosome (but not in its centromeric region) .The first work on screening the genome to establish a correlation of BAP with nucleotide sequences.42 demonstrated that there are several genes (in the largest degree DGK H, which codes for the key protein of the lithium-sensitive mechanism of inositol phosphorylation), each of which significantly increases the risk of the disease (to a moderate extent), suggesting a possible genetic heterogeneity of the disease.
As in schizophrenia, in the postmortem brain samples there is a change in the expression of some molecules, such as GAD67 and rylin, but it is not clear what causes them - the pathological process or the taking of medications.The search for endophenotypes for more confident detection of genetic bases disorder.
Although according to Krepelin. two thirds of TIR cases were diagnosed in women, according to more recent data. bipolar forms of affective disorders are more likely to affect men, and monopolar women are three times more likely to develop in women. Affective psychosis often develops in women during menstruation, after childbirth, in involution, which confirms the involvement of the endocrine factor in its pathogenesis. Established, that in women who have suffered postpartum depression, bipolar psychosis subsequently appears more often. However, it is not clear whether postnatal depression is a provoking factor, or birth causes a debut of bipolar disorder, which is diagnosed as a major depression.
It is known that phase formation in bipolar disorder depends on the effect of external (psychogenic and somatogenic) factors. It was revealed that they had a distinct effect on the appearance of manifest phases in the monopolar and bipolar (with the predominance of one of the two poles) type of course of phase affective disorders. But if in the picture of monopolar depressive disorder the provoking factors, reflecting on the clinical picture of the manifest state, make it similar to the reactive structure of depression and, therefore, play a pathogenetic role (for this form of the disorder, retention of reactive phase formation is characteristic throughout the course of the disease), then in cases monopolar manic or bipolar affective disorder, the role of external factors is determined only as a provoking debut of the disease, and further The phase of the disease occurs most often spontaneously. . Moreover, the more the manic affect is present in the picture, the less influence exogenous factors have on the phase formation.
Women who have experienced a psychiatric episode of any nature directly in the postpartum period have an increased risk of developing bipolar psychosis. In particular, if such an episode occurred within 14 days after birth, the risk of developing bipolar disease subsequently increases fourfold. In addition, labor can provoke bipolar disease in women who previously had psychiatric problems (14% of those treated with psychotropic drugs in the preceding 15 years).
Characteristic features of personality
Some personality traits are associated with an increased risk of developing bipolar disorder. These include, for example, the melancholic type of personality and statotimical type, which are determined primarily by an emphatic orientation toward orderliness, constancy, responsibility. Other authoritative specialists also noted that increased conscientiousness and psychohastenic personality traits in the period before the disease are more often noted in the unipolar depressive version of the MDP.55 It is also established (BS Belyaev, 1989) that in unipolar variants of the course of affective psychosis, 70%) than with the bipolar proper (34%), before the disease schizoid personality traits were observed.
The risk factor is also the premorbid personality characteristics associated with emotional instability, which is expressed in excessive affective reactions to external causes, as well as in spontaneous mood swings. On the other hand, the people predisposed to the disease, suffering from the phenomena of scarcity in any sphere of mental activity. In their personal manifestations, the inadequacy of the emotions proper, the conservatism of the individual predominate; their mental reactions are characterized by rigidity, monotony and monotony.
Clinical picture, course
The number of phases possible for each patient is unpredictable - the disorder can be limited even to a single phase (mania, hypomania or depression) throughout life, but in this case it is more correct to talk about a long, sometimes decades-long intermission. The disease can only appear manic, only hypomaniacal or only depressive phases or their replacement with the right or wrong alternation (see above).
The duration of the phases ranges from several weeks to 1.5-2 years (an average of 3-7 months), with (hypo) mania phases on average three times shorter than depressive.
The duration of "light" gaps (intermissions or interphase) between phases can be from 3 to 7 years; A "light" gap may be completely absent. Atypical phases can manifest themselves as a disproportionate expression of core (affective, motor and ideator) disorders, incomplete development of stages within a single phase, the inclusion in the psychopathological structure of the phase of obsessive, senestopatic, hypochondriac, heterogeneous delusional (in particular, paranoid).
Ballucinatory and catatonic disorders
The damage from bipolar depressions exceeds the damage from manic, as patients spend more time in depression, they have much more violations in professional, social and family life, the risk of suicide during and after depression is high.
The course of the manic phase.
The manic phase is represented by a triad of the main symptoms:
- high mood (hypertension)
- motor excitement
- ideal-mental excitement (tahipsihiya)
During the "full" manic phase, five stages are distinguished.
The hypomanic stage (F31.0 according to ICD-10) is characterized by an elevated mood, a feeling of spiritual uplift, physical and mental vigor. Speech verbose, accelerated, the number of semantic associations decreases with the growth of mechanical associations (by similarity and consonance in space and time). Characteristically moderately expressed motor excitement. Attention is characterized by increased distractibility. Characterized by hypermemia. Moderately reduces the duration of sleep and increases appetite.
The stage of pronounced mania is characterized by a further increase in the severity of the main symptoms of the phase. Patients constantly joke, laugh, against the background of which short-term outbursts of anger are possible. Speech excitation is pronounced, reaches the degree of jumping of ideas (Latin fuga idearum). Pronounced motor excitement, pronounced distractibility lead to the inability to lead a patient with a consistent conversation. Against the background of a re-evaluation of one's own personality delusions of grandeur appear. At work, patients build bright prospects, invest money in unpromising projects, design insane designs. Duration of sleep is reduced to 3-4 hours per day.
The stage of manic frenzy is characterized by the maximum severity of the main symptoms. Abrupt motor excitement is disorderly, speech is outwardly incoherent (in the analysis it is possible to establish mechanically associative connections between the components of speech), consists of fragments of phrases, individual words or even syllables.
The stage of motor rest is characterized by reduction of motor excitement against the background of persistent high mood and speech excitement. The intensity of the last two symptoms also gradually decreases.
The reactive stage is characterized by the return of all the constituent symptoms of mania to normal and even some decrease in comparison with the norm of mood, easy motor and ideator retardation, asthenia. Some episodes of the stage of severe mania and the stage of manic frenzy in patients can amnesize.
To determine the severity of the manic syndrome, the evaluation scale of Yang's mania is used.
The course of the depressive phase
The depressive phase is represented by the triad of symptoms opposite to the manic stage: depressed mood (hypothyroidism), delayed thinking (bradypsychia) and motor retardation. In general, BAP is more likely to be depressive than manic. For all stages of the course of the depressive phase, daily fluctuations are characteristic, with an improvement in mood and overall well-being in the evening hours.
In patients, the appetite disappears, the food seems tasteless ("like grass"), the patients lose weight, sometimes significantly (up to 15 kg). At women for the period of depression menstruation disappear (amenorrhea). With a shallow depression, the daily mood swings characteristic of the BAP are noted: the state of health is worse in the morning (wake up early with a feeling of anguish and anxiety, are inactive, indifferent), by the evening the mood and activity are somewhat increased. With age, in the clinical picture of depression, an increasing place is occupied by anxiety (unmotivated anxiety, premonition that "something must happen", "inner excitement").
During the depressive phase four stages are distinguished:
The initial stage of depression manifests itself as an inadequate weakening of the general mental tone, a decrease in mood, mental and physical performance. Characterized by the emergence of moderate sleep disorders in the form of difficulty falling asleep and its superficiality.
The stage of increasing depression is already characterized by a clear decline in mood with the appearance of an alarming component, a sharp decrease in physical and mental performance, motor retardation. The speech is slow, terse, quiet. Sleep disorders result in insomnia. A marked decrease in appetite is characteristic.
Stage of severe depression - all symptoms reach maximum development. Characterized by severe psychotic affects of anguish and anxiety, excruciatingly experienced by patients. Speech is abruptly slow, quiet or whispered, answers to questions are monosyllabic, with a long delay. Patients can sit or lie in one position for a long time (so-called "depressive stupor"). Anorexia is characteristic. At this stage, depressive delusional ideas (self-blame, self-abasement, self-immorality (sinfulness), hypochondriacal) appear. Also characteristic is the appearance of suicidal thoughts, actions and attempts. Suicidal attempts are most frequent and dangerous at the beginning of the stage and at the exit from it, when there is no pronounced motor retardation in the background of severe hypothyroidism (extremely depressed mood). Illusions and hallucinations are rare, but they can be (mostly auditory), more often in the form of voices, reporting on the hopelessness of the state, the meaninglessness of being, recommending suicide.
The reactive stage is characterized by the gradual reduction of all the symptoms, asthenia persists for some time, but sometimes, on the contrary, there is some hypertension, loquacity, increased motor activity.
It is worth noting that with the BAR, a variant of the depressive phase is often observed, close to atypical depression, in which there is no decrease in appetite, body weight and insomnia, but on the contrary, hyperphagia, weight gain and hypersomnia; characterized by a feeling of heaviness in the body, emotional lability, a high level of psychomotor retardation, a high level of anxiety, sensitivity to frustration situations, irritability. Some authors consider these manifestations to be the most significant clinical signs of bipolar depression, contrasting them with signs of unipolar depression, for which, in their opinion, "more typical" depressive symptoms are characteristic.
A comparative analysis of the population of people with depression in the EPIDEP study showed that with the comparable severity of major depressive symptoms in bipolar patients, depersonalization, derealization, weight gain, hypersomnia were more common than in patients with unipolar depression, and in addition, more intense suicidal thoughts and ideas of self-blame. Patients with unipolar depression often noted symptoms such as motor and intellectual retardation, decreased energy, pessimistic assessment of prospects.
In both groups, the symptoms of anxiety were present in the structure of depression, but in somatic patients, in the Hamilton anxiety score, somatic manifestations predominated - muscle tension, gastrointestinal symptoms and dysuria, and in bipolar patients, the actual psychological manifestations of anxiety were more pronounced - a feeling of extreme tension, anxious anticipation and anxious anticipation, obsessional and phobic symptoms.
Variants of the course of the depressive phase
- simple depression - triad of depressive syndrome without delirium;
- hypochondriacal depression - depression with affective hypochondriac delirium;
- delusional depression (see "Kotar syndrome");
- Agitated depression is characterized by the lack or weak severity of motor retardation;
Anesthetic depression is characterized by the presence of the phenomenon of painful psychic insensitivity (Latin anaesthesia psychica dolorosa), when the patient claims to have completely lost the ability to love loved ones, nature, music, lost all human feelings in general, became completely insensitive, and this loss is deeply experienced as an acute heartache.
Affective mixed episodes are characterized as states in which one of the components of the triad (mood, motor activity, thinking) is opposed to the pole of other components. These states include, on the one hand, agitated depression, anxious depression and depression with a jump in ideas; on the other hand, inhibited mania, unproductive mania and dysphoric mania.20 Also, mixed episodes include conditions in which the symptoms of hypomania, mania and depression alternate rapidly (usually within a few hours).
Mixed affective episodes are relatively common (especially in young patients): according to some data, 13.9-39.4% and 5.1-12.0% of patients with type I and IIB type II, respectively. These conditions cause difficulties in diagnosing and choosing a method of treatment, often are resistant.20 The boundaries between "pure" mania and mixed state are fuzzy, since depression often disappears behind a manic facade and is easily provoked by situational factors.
Difficult for diagnosis, a variant of the flow, which is often confused with mixed states. With rapid-cyclic bipolar disorder, there are more than four episodes of mania, depression or mixed state during the year. They can be separated by a period of remission or they can end with an "inversion of affect" - a direct change of phase to the opposite one. Each depressive episode lasts no less than two weeks, every manic or mixed episode - at least one week, each hypomaniac episode - at least 4 days. There are concepts of "ultrafast" cycles (4 or more affective phases within 1 month).
For patients with fast cycles, an unfavorable individual prognosis is characteristic, often resistance to treatment, low compliance. In many patients, rapid cycling may be due to the use of antidepressants - both without normotimics, and in combination with them.
From a formal point of view, at least two affective episodes are the obligatory criterion of diagnosis, of which at least one must be (hypo) manic or mixed. Of course, in determining the diagnosis, the physician considers many more factors and makes decisions based on their totality. In this case, great attention should be paid to differential diagnosis (see below). In particular, affective episodes can be caused by exogenous causes - for example, reactive depressive episodes (reaction to psychotraumatic events); hypomanic episodes caused by hyperstimulation, chemical or non-chemical (eg, lack of sleep); etc. Ignoring such cases can lead to overdiagnosis of the BAP.
However, mistakes of the opposite kind occur more often: since hypomaniac episodes often drop out of the doctor's field of vision.65 or the patient himself (which may not count as painful conditions), he may be mistakenly diagnosed with either regular or periodic depression. It is possible that with the introduction in the United States of the classification of a separate nosological unit of BAP II (without manic episodes), the observed increase in the diagnosis of bipolar disorder in this country is associated.
The earliest possible diagnosis of bipolar illness is essential: if treatment begins, when the patient has suffered only one (hypo) manic episode, it is twice as effective as the treatment started after several affective episodes. However, according to American researchers, more than a third of patients with bipolar disorder correctly diagnosed only after 10 or more years after the first episode of the disease.
Differential diagnosis of BAP is necessary for almost all types of mental disorders: unipolar depression, personality disorders, schizophrenia, substance abuse and affective disorders, with somatic or neurological causes, neuroses, infectious, psychogenic, toxic, traumatic psychoses, oligophrenia.
If a patient has a mania that develops against the background of taking antidepressants, but no history of manic episodes, the most likely diagnosis should be a mood disorder caused by a drug. About the diagnosis of bipolar disorder, one can think only if the symptoms of mania were observed before taking an antidepressant, or if the symptoms of mania last at least a month after the antidepressant is discontinued. Similar diagnostic considerations should be applied to patients who abuse psychoactive substances (for example, cocaine, amphetamine) with a psychotomimetic effect capable of causing manic conditions.
Differential diagnostics of BAP with schizophrenic disorders and unipolar recurrent depression are significant difficulties.68 .. Russian psychiatry is characterized by a historically established tradition of extensive schizophrenia diagnostics, leaving only bouts of "pure" depressions and mania within the boundaries of the BAR with their inherent false ideas . In addition, many of the symptoms related to the diagnostic criteria of the manic state (such as, for example, very pronounced verbal stimulation) are often considered erroneously in the context of the symptomatology of the schizophrenic spectrum; Anergic depression is often treated within the framework of deficit disorders, and anxiety-depressive affect is biased in the framework of the paranoid syndrome. In many cases, emotional-volitional and cognitive manifestations of neuroleptic parkinsonism are accepted as "schizophrenic defect", which disappear without a trace after the patient stops taking neuroleptics.
The erroneous diagnosis of schizophrenia in bipolar disorder is also dangerous, because it leads to the appointment of powerful classical (typical) antipsychotics for a long time, often in deposited form, and as a result to the formation of protracted, non-transformed manic states or to the inversion of affect with long adynamic depression. This can lead to disability of patients, as well as chronic extrapyramidal symptoms due to prolonged use of such drugs. Hyperdiagnosis of schizophrenia is a factor of stigmatization of patients in society, causes errors in forensic psychiatric practice, unjustified transfers to disability and increased economic costs.
Very important is the early diagnosis of hypomanic conditions, since failure to identify them in patients with type II BAR leads to the diagnosis of recurrent depression and the appointment of an inadequately long period of antidepressants, which may lead to further weighting of the course of bipolar affective disorder and the formation of a hard-to-treat rapid cyclicity . Such errors, as well as erroneous diagnosis of schizophrenia, are common in Russia and other countries of the post-Soviet space, leading to an aggravation of the disease, social disadaptation and disability.
Hypodiagnosis BAP often occurs in Western countries. Thus, according to a study by Hirschfeld et al. (2003), 69% of patients before diagnosis of BAP were observed with other diagnoses: unipolar depression (60%), anxiety disorder (26%), schizophrenia (18%), borderline or antisocial personality disorder (17%), alcohol abuse or other substances (16%), schizoaffective disorder (11%). In several independent diagnostic studies, it was found that almost 50% of young patients with a diagnosis of recurrent depression subsequently have a bipolar flow type - in other words, they suffer at least one manic or hypomanic episode. The correct diagnosis of bipolar disorder occurs on average only 10 years after the onset of the disease.
Frequent, prolonged or recurrent hallucinations are not characteristic for BAP, their presence allows attributing the disease to schizophrenia or schizoaffective disorder.
Since patients with impaired thyroid function often develop depressive or manic symptoms, in the presence of mood disorders in a patient, it is advisable to evaluate the function of the thyroid gland in order to identify or exclude the somatic cause of mental disorders. Correctly prescribed treatment of hypo- and hyperthyroidism leads in most cases to the reduction of mental symptoms.
It is worth noting that antidepressant therapy for hypothyroidism, as a rule, is ineffective; In addition, in patients with impaired thyroid function, the risk of unwanted effects of psychotropic drugs is increased. In particular, tricyclic antidepressants (and, more rarely, MAO inhibitors) can lead to rapid cycling in patients with hypothyroidism. The appointment of lithium drugs in hyperthyroidism (thyrotoxicosis) can lead to a short-term symptomatic improvement with the subsequent increase in symptoms of hyperthyroidism and the development of ophthalmopathy.
For treatment of bipolar affective disorder type I and II and prevention of both phases of the disease, lithium preparations, antiepileptic drugs, such as valproate, carbamazepine and lamotrigine, and some of the atypical antipsychotics, in particular quetiapine and olanzapine, are used. All these drugs are called normotimics (mood stabilizers, thimostabilizers). They can be used in combination with each other, while it is undesirable to use two drugs of the same group (for example, two neuroleptics).
Since the discrete course of psychosis - as opposed to continuous - is prognostically favorable, achieving remission is always the main goal of therapy.
To stop the phases, "aggressive psychopharmacotherapy" is recommended to prevent the formation of resistant states. It is meant that it is necessary to start treatment with the appointment of a relatively high dose of drugs and rapidly increase dosages to the optimal level in this particular case, focusing on the patient's condition. However, in the case of bipolar disorder, special attention should be paid to avoid phase reversal, that is, a direct reversal of the phase due to excessively active anti- manic or antidepressant treatment. Phase inversion (i.e., actual direct phase change by circular flow type, without a "light" gap between phases) is prognostically unfavorable and worsens the overall condition of the patient.
Preparations of lithium, valproate and carbamazepine are effective both in the treatment and prevention of manic and depressive phases, but primarily in the treatment of mania and in preventive therapy; they are less effective in the treatment of bipolar depression. Lamotrigine is believed to be effective primarily in the treatment and prevention of depressive phases and is ineffective in treating manic episodes. However, its effectiveness in depressive phases (as well as in rapid cycling) is also questioned: it is argued that, given negative studies that were not initially published, the drug has very limited, if any, efficacy in acute bipolar depression and rapid cycling
In all affective disorders, treatment with lithium drugs significantly reduces the incidence of suicide, as confirmed by a meta-analysis of randomized trials. This is not only due to the treatment of the disease, but also because lithium reduces aggressiveness and, possibly, impulsivity. In addition, with lithium treatment, the suicide rate decreases compared to treatment with other drugs, and overall mortality also decreases.
Neuroleptics (they are also antipsychotic drugs) are effective for short periods of treatment of the manic phase, while lithium preparations are preferably used for long-term treatment. Antidepressants can be used only during the depressive phase, and necessarily in combination with normotimics. Three atypical antipsychotics (lourazidone, olanzapine and quetiapine) have shown efficacy in the treatment of bipolar depression in the form of monotherapy, whereas only olanzapine and quetiapine have proved the effectiveness of a wide range of preventive therapies (that is, the prevention of all three types of phases - manic, mixed and depressive). However, olanzapine had a less favorable risk / benefit ratio than lithium drugs during preventive therapy.
There is also the view that antipsychotics should preferably be prescribed in the BAR only if the patient exhibits marked excitement or psychotic manifestations.
The effectiveness of treatment of bipolar disorder essentially depends on the number of the transferred episodes of the disease. As already noted, treatment started after the first (hypo) manic episode is twice as effective as the treatment started after several affective episodes. For example, with monotherapy with olanzapine, recommended as a first-line drug for the treatment of manic episodes, and in combination with fluoxetine and for depressive BAP phases, a favorable reaction in patients who had 1-5 episodes was 52-69% during treatment of manic phases and 10 -50% during maintenance therapy. In the treatment of patients who had suffered more than 5 episodes, the effect was significantly less: 29-59% and 11-40%, respectively. The likelihood of recurrence (hypo) manic or depressive episode, despite treatment with olanzapine, doubles in patients who have suffered more than 5 affective episodes. Also, with maintenance therapy, the probability of relapse increases by 40-60%, respectively, in the groups of patients who have suffered from 1 to 5, 6-10 and more than 10 episodes of the disease.Since other data show that residual symptoms, concomitant diseases and non-adherence to the treatment regimen play a large role in the recurrence of the disease, these factors also merit increased attention for more successful treatment over a long period of time and in terms of the outcome of the disease.
Resistant bipolar disorders often lead to polypharmacy (the administration of several drugs at the same time). In these cases, the number of prescription drugs is sometimes excessive, and several drugs from one pharmacological group are sometimes prescribed: a similar scheme can include, for example, six drugs, including two antipsychotics and two benzodiazepines. Such an appointment is unjustified, and a prudent decision in this case will be the gradual elimination of even a few drugs and a critical evaluation of the value of others. It is desirable to limit the treatment schedule to a maximum of three psychotropic agents of various pharmacological groups (eg, lithium, neuroleptic and antidepressant).
Discussing the issue of the place of antidepressants in the therapy of bipolar depression is one of the most difficult and lengthy discussions in psychiatry. One of the reasons for this in the ability of antidepressants to lead in bipolar depression to such consequences as increased risk of emotional instability and the provocation of manic conditions. In addition, evidence on the effectiveness of antidepressants, on the one hand, and mood stabilizers (normotimics), on the other hand, is interpreted in different ways: some authors insist that the data on the benefits of antidepressants in bipolar depression are not clear enough, others (in assessing the same a database of evidence-based medicine), on the contrary, emphasize that there is more evidence of the effectiveness of antidepressants than normotimics.
Despite disagreements in the development of recommendations for drug therapy, according to evidence-based medicine, mood stabilizers are still the gold standard in treatment, and when signs of depression appear, it is recommended first of all to optimize the dose of stabilizers.
In most clinical recommendations, antidepressants retain their role in the therapy of bipolar depression, but they are recommended to be used as short as possible and from the very beginning to be combined with normotimics that prevent phase reversal-valproate, carbamazepine and oxcarbazepine, lithium preparations, and atypical antipsychotics. In addition, normotimics have their own antidepressant effect, and besides, they allow to overcome resistance to antidepressants. For example, according to a 2007 study, lamotrigine can treat the depressive phase without causing mania, hypomania, mixed states, or rapid state changes.
In one study, it was shown that the combination of two normotimics, one of which is lithium, and the second an anticonvulsant drug (carbamazepine, lamotrigine or valproate), is not inferior to the combination of normotimic and antidepressant in the effectiveness of relief of depressive symptoms in patients with bipolar disorder, but somewhat worse is transferred by patients.
When assigning high doses of lithium or carbamazepine in clinical practice, there may be problems associated with tolerability. In addition, prolonged and / or intensive administration of these two drugs can lead to hypothyroidism, which, in turn, leads to affective instability. Lithium is also characterized by such shortcomings as a narrow therapeutic window and the difficulty of determining the dose at the concentration achieved, which makes it potentially a toxic and unsafe drug with a large number of side effects.
Depakin (sodium valproate), in contrast to lithium and carbamazepine, does not affect the function of the thyroid gland. In addition, it is characteristic for him to reduce the frequency of phase states in patients with fast cycles. Only for this drug there is a recommendation for forced dose build-up, so depakin is the drug of choice to prevent the development of not only a manic, but also an emerging depressive phase. According to some reports, depakin is a means of choosing in the cupping of anxiety symptoms in the dynamics of the depressive phase - both in the prodromal period and in the stage of the unfolded depressive episode. Among the atypical antipsychotics, normotimics are most often referred to as quetiapine, olanzapine, clozapine and risperidone. Fluoxetine is especially effective in combination with olanzapine. A combined preparation is also available - olanzapine + fluoxetine - Symbiax (English) Russian. for the treatment of both bipolar depressive episodes and resistant depressions.
When using atypical antipsychotics, such side effects as metabolic disorders (at risk of obesity, diabetes, cardiovascular diseases), sedation and drowsiness, increased prolactin levels, and (much less frequently than when taking typical antipsychotics) may occur - extrapyramidal disorders . It is worth noting that, caused by some atypical antipsychotics (primarily risperidone and amisulpride), hyperprolactinaemia in long-term therapy alone can lead to anxious and depressive disorders.
Although the atypical antipsychotic aripiprazole is often used in bipolar depression, the data regarding the possibility of its use in the depressive phase are ambiguous, as shown by the systematic review published in the Annals of General Psychiatry in 2009; the reason for this is poor tolerance in studies.97 .. The side effects typical of most other atypical antipsychotics are not very typical for aripiprazole.98 However, it can cause, in particular, insomnia and agitation.
Most recommendations for the treatment of bipolar disorder indicate the effectiveness of antidepressant medications in combination with normotimics in relieving the depressed episode.58 However, the results of studies on the effectiveness of antidepressants in bipolar depression are contradictory: in addition to positive results, data on the insufficient effectiveness of antidepressants in this disorder or even the lack of their advantages over placebo. So, the FDA analysis found that most of the studies with a negative result were not published or presented as studies with a positive result.
Some authors recommend the use of antidepressants in bipolar depression only in cases where depression in patients does not go away, despite the therapy with normotimics. It is also believed that the appointment of antidepressants in small doses can reduce the risk of switching depression to a manic or mixed state or the development of rapid cycling.
Antidepressants for both unipolar depression and bipolar are selected taking into account the structure of depression. If the choice of an antidepressant is incorrect, without taking into account the prevalence of a stimulant or sedative component in its action, taking the drug may lead to a worsening of the condition: when a stimulating antidepressant is prescribed, the worsening of anxiety, anxiety, and suicidal tendencies; with the appointment of a sedative - to an even greater psychomotor retardation (lethargy, fatigue, drowsiness) and reduced concentration of attention.
In the presence of symptoms of classical melancholic depression, in which depression, apathy, and decreased motivation come to the fore, it is advisable to prescribe stimulant antidepressants, such as fluoxetine, venlafaxine, milnacipran, bupropion and similar preparations. With adynamic depression, when the ideator and motor retardation come to the fore, stimulating antidepressants are also preferred. Very good results with this type of depression gives citalopram, although its effect is balanced, rather than stimulating.
If anxiety and anxiety are at the forefront, then antidepressants of sedative action are used: paroxetine, escitalopram, mirtazapine.
A special group of depressions are those species in which there is simultaneous anxiety and inhibition: the best result in treatment has been sertraline - it quickly stops both the anxiety and phobic component and melancholy. The source is not indicated 283 days., Although at the beginning of the therapy it can intensify manifestations anxiety, which sometimes requires the appointment of tranquilizers.
The property of provoking mania in patients with bipolar depression is more typical of tricyclic antidepressants.58, and selective serotonin reuptake inhibitors and MAO inhibitors cause phase inversion much less often.19 .. In particular, in the treatment of bipolar depression, and especially in the structure of type I BAP , phase inversion (transition to the manic phase) in the case of tricyclic antidepressant imipramine was observed in approximately 25% of cases. however, there are other data: for example, according to one meta-analysis, tricyclic antidepressants caused an affect inversion in 11-38% of cases.
The phase inversion induced by antidepressants is considered an unfavorable factor, weighting the overall course of bipolar disorder. According to modern ideas, the number of previous episodes can determine the degree of risk of subsequent exacerbations - in other words, "the phase provokes a phase". The frequency of antidepressant-induced inversions is dose-dependent: it is higher the higher the dosage level used. Tricyclic antidepressants can shorten the light intervals between episodes of exacerbation of the disease.
Approximately in 25% of patients with BAP, uncontrolled use of antidepressants can lead to the formation of a rapid cyclic and continual flow.
The main role in the treatment of the manic phase is played by normotimics (lithium preparations, carbamazepine, valproic acid). Lamotrigine, used in the depressive phase of the disease. ., is not considered effective in treating a manic episode. However, it is effective in the prevention of the manic phase or in the appointment for enhanced remission.
In some cases, to quickly eliminate the symptoms of manic and mixed phases, there is a need for antipsychotics, with priority being given to atypical. Atypical antipsychotics are also often combined with lithium and valproic acid as the first line of therapy for manic and mixed phases.
With the use of classical (typical) antipsychotics, there is a much greater risk not only of phase inversion (development of depression). and neuroleptic-induced deficiency syndrome, but also extrapyramidal disorders, to which patients with BAP are particularly prone - in particular, it concerns tardive dyskinesia, irreversible disability leading to disability. According to the results of the meta-analysis, typical neuroleptics (haloperidol, chlorpromazine, etc.) in the treatment of manic episode are significantly inferior to lithium salts. Lithium with "pure" mania is preferable from the pathogenetic point of view and is effective from the point of view of not only cupping, but also prevention of phases, while typical neuroleptics practically do not influence the mechanism of phase flow.
The risk of extrapyramidal disorders exists even when some atypical antipsychotics are used in patients in the manic phase: ziprasidone, risperidone and aripiprazole (and also in the use of quetiapine and aripiprazole in the depressive phase .-- The latter, in patients suffering from bipolar disorder, is associated with the risk of predominantly akathisia ).
The drugs of choice for fast cycles are normotimics. Antidepressants and typical (classical) antipsychotics should be avoided, since the former increase the risk of inversion of affect, and neuroleptics - the risk of chronic extrapyramidal symptoms.61 .. Antidepressants in rapid cycling should not be used even in combination with normotimics. Only sometimes - with severe suicidality during depressive episodes - short-term treatment with antidepressants may be justified.
There is an opinion that anticonvulsants with rapid cycling are more effective than lithium, but this opinion is disputed.
Prevention of exacerbations of BAP
For the purpose of prevention, normotimics are used, primarily lithium preparations, carbamazepine (finlepsin), valproate. Separately, it should be noted lamotrigine, which is particularly indicated in a rapidly cyclic course with a predominance of depressive phases. The source is not specified for 2 days. Very promising in this respect are atypical antipsychotics, in particular quetiapine.
Psychotherapy- among the tasks of psychotherapy in bipolar affective disorder include, in particular, training in the management of symptoms, improving social and professional functioning, and patient compliance with the medication regimen. The strongest argument in favor of the use of psychotherapy in BAP is the effectiveness of helping patients to cope with stress factors. These or other life events and family conflicts serve as risk factors for aggravation of bipolar disorder, and psychotherapy can be aimed at these factors, allowing to teach patients adaptive coping mechanisms that are important for the prevention of relapses in the future.
Of the specific methods of psychotherapy in the BAP can be applied cognitive-behavioral therapy, interpersonal therapy, family intervention, social support, therapy of social rhythms. To solve the problems of supportive psychopharmacological treatment, compliance therapy is used (compliance-therapy).
Family therapy (family intervention, family-focused treatment) showed significant efficacy in BAP. The goals of family therapy for bipolar disorder are to help the patient and his or her family:
- in the integration of experiences associated with episodes of mood swings;
- in accepting the inevitability of affective episodes in the future;
- in taking dependence on normotimics for the prevention and elimination of symptoms;
- in distinguishing the personality of the patient and the symptoms of his disorder;
- in the identification and ability to cope with stressful life events that provoke relapses of the BAR;
- in the restoration of functional relationships after the episode of mood swings.
Patients with BAP are very sensitive even to minimal changes in sleep habits - wakefulness. Thus, manic episodes are often provoked by life events that change these habits (for example, the change of time zones during air travel). Therefore, the positive role played by teaching patients the regulation of their social rhythms, especially on the eve of life events that can break these rhythms; this training can improve the prognosis of bipolar disorder.
A quantitative assessment of more than 30 studies shows that comparing patients to their condition with the condition of other patients (both with the heavier and with the lighter than he) beneficially affects his health. This is one factor in the positive impact of patient support groups.
According to the famous American clinical psychologist Kay Jamieson, a great role in overcoming the disease is the willingness of both the patient and others to openly discuss the emerging problems. Such openness, according to Dr. Jamieson, helps to overcome the stigmatization of patients, which, in turn, facilitates the return of the latter to a normal lifestyle.
Other methods of treatment
The method of deep transcranial magnetic stimulation (Deep TMS) has been approved by CE Mark CE for treatment of BAP (on a par with other diseases).
The efficacy of omega-3-unsaturated fatty acids in BAP is also shown, the use of which, according to the results of studies, contributes to mood stabilization and relief of depression, prevention of relapses.
Forecast and expertise
Depending on the frequency and duration of attacks and "light" intervals, patients can be transferred to I, II, III disability groups or even remain able to work and be treated on a sick leave sheet (with a single attack or with rare and short-lasting seizures). When committing a socially dangerous act during an attack, patients are more often considered insane, when performing a socially dangerous act during the intermission, the patients are more often recognized as sane (the expertise of each case is quite complicated, especially for mild forms of the disease, it is necessary to carefully compare all the circumstances of the case with the degree of severity of mental disorders of the patient ). In Russia, patients with bipolar affective disorder are considered unfit for military service on the conclusion of a military medical commission.