Category: Bipolar Disorder

Return to blog >

 

 

 

 

 

 

 

 

 

By Danielle Johnson, MD, FAPA
Chief Medical Officer, Lindner Center of Hope

Mood disorders have distinct disturbances in emotions. Low moods are called depression and high moods are called hypomania or mania. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) categorizes mood disorders into bipolar disorders and depressive disorders. Mood disorders include major depressive disorder, bipolar I and bipolar II disorder, disruptive mood dysregulation disorder, premenstrual dysphoric disorder, persistent depressive disorder, and cyclothymic disorder. In the U.S., almost 1 in 10 (9.7%) adults experienced any mood disorder in the past year, with past year prevalence of any mood disorder being higher for females (11.6%) than for males (7.7%). More than 1 in 5 (21.4%) U.S. adults will experience any mood disorder in their lifetime. Mood disorders are common in children and adolescents with an estimated 15% having any mood disorder. Major depressive disorder and bipolar disorder are the most common mood disorders with 8.3% of all U.S. adults experiencing at least one major depressive episode in the past year and 2.8% of U.S. adults having bipolar disorder in the past year.

When people experience symptoms of a mood disorder that do not look like major depression or bipolar disorder this can lead to a delay in diagnosis and treatment as they might have difficulty articulating their symptoms and healthcare professionals might not ask questions about other disorders. Although other mood disorders are less common and less severe, they still impact quality of life and functioning.

Persistent depressive disorder (dysthymia) was added to DSM-5 in 2013, combining some criteria of dysthymic disorder and chronic major depressive disorder. With PDD, depressed mood occurs for most of the day, for more days than not, for at least two years (one year for children and adolescents). During a two-year period (one year for children or adolescents), a person has never been without symptoms for more than two months at a time. A major depressive episode can occur before PDD, or people can experience “double depression” when major depressive episodes occur during PDD.

Symptoms can include poor appetite or overeating; insomnia or hypersomnia; low energy or fatigue; low self-esteem; poor concentration or difficulty making decisions; or feelings of hopelessness. PDD is associated with greater childhood adversity and maltreatment, childhood loss of a parent, earlier onset of depression, and higher rates of chronic depression in relatives. People with PDD also experience a higher number of traumatic events during their lifetime. The 12-month prevalence ranges from 0.5% to 1.5%.

Cyclothymic disorder consists of episodes of hypomanic and depressive symptoms that do not meet the full criteria for bipolar or major depressive disorder. The lifetime prevalence is approximately 0.4%-1%. Symptoms last two years, for more days than not with stability of mood for no longer than two consecutive months. Symptoms of depression can include depressed mood, irritability, hopelessness, helplessness, insomnia, fatigue, anhedonia, avolition, negativity of affect, and suicidal ideation. Hypomanic symptoms can include impulsivity, grandiosity, racing thoughts, increased sociability, excess physical activity, and increased speech production.

People with cyclothymia may experience emotional lability, hypersensitivity, recurrent interpersonal altercations, incidents of self-harming, episodes of excessive gambling, reckless sexual activity, multiple divorces, legal or financial problems, and recurrent job loss. The chronic and pervasive nature of cyclothymic disorder can lead to misdiagnosis with cluster B personality disorders.

There are no FDA-approved medications for PDD or cyclothymic disorder. Your psychiatrist or psychiatric nurse practitioner will take a thorough history including past medical history, previous medical trials, and other psychiatric diagnoses and work with you to develop a treatment plan and choose appropriate medications and psychotherapy to treat depressive and/or hypomanic symptoms.

Sekhon S, Gupta V. Mood Disorder. [Updated 2023 May 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK558911/

https://www.nimh.nih.gov/health/statistics/any-mood-disorder

https://www.nimh.nih.gov/health/statistics/major-depression

https://www.nimh.nih.gov/health/statistics/bipolar-disorder

Patel RK, Aslam SP, Rose GM. Persistent Depressive Disorder. [Updated 2024 Aug 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from:

https://www.ncbi.nlm.nih.gov/books/NBK541052/

Patel RK, Aslam SP, Rose GM. Persistent Depressive Disorder. [Updated 2024 Aug 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from:

https://www.ncbi.nlm.nih.gov/books/NBK541052/

Return to blog >

By Peter White, M.A., LPCC, LICDC, Lindner Center of HOPE Outpatient Therapist

The problem during Bipolar Mood Disorders is a pattern of swings of the essential elements of mood between the two poles, like the North Pole and South Pole, of Mania and Depression. These swings are not moodiness, which are swings of mood throughout a day. A Bipolar swing is a distinct period of at least one week when the full spectrum of mood elements exhibits depressive and/or manic elements.

Although thought of as a subjective experience, mood deeply influences three areas. First is metabolism – sleep, appetite, libido and energy levels. Second, mood influences both motivation as well as the ability to experience pleasure and/or a sense of accomplishment. Thirdly, mood deeply influences interpretations within thoughts from positive to neutral to negative.

So, we can think of this first spectrum of mood disorder along an axis of depression to neutral to manic. Therefore, a depressed mood will depress metabolism. A person will have difficulty with sleep through either excessive or inadequate or disrupted sleep, loss of appetite or excessive eating despite disrupted appetite, loss of libido as well as loss of energy. Depression will hinder motivation making it difficult to experience the drive to initiate activities as well as hinder pleasure or the reward of activity. This is a very difficult cycle when it is hard to get active in the day compounded by not finding any pleasure or reward in the day’s activities. Lastly, depression will darken the flow of thoughts adding many themes of hopelessness, helplessness, worthlessness and guilt into our thought process.

Conversely, mania will elevate the same essentials. It will increase energy levels often in the face of declining sleep hours. It will increase libido, increase excessive and/or absence of appetite. It will increase motivation often leading to excessive engagement of plans or activities and will create a compounding loop of all activity feeling especially pleasurable or rewarding. Again, conversely is will paint thinking with elevated judgements of specialness, invulnerability, and inevitable positive outcomes.

The second spectrum of mood disorders, like most other behavioral health problems, is along the spectrum of severity – mild to moderate to severe. If you combine this spectrum of severity along with the first spectrum of depressive to manic, we see how varied and individualized any person’s experience with Bipolar Mood disorders can be.  Most people can relate to some degree of depression during periods of their life with perhaps a few weeks or month of low energy, noticing that they are not getting the same rewards in their regular activity as well as perhaps noticing they are thinking unusually negatively about themselves and their outlook on life. We might call this a mild, brief depressive episode. But the reality is that depression is one of the most disruptive and costly of all health conditions as recognized by the World Health Organization. This mean that depression is often moderate or severe to very severe and can disrupt functioning on every level for weeks to months if not years. A severe depression can make it difficult to get out or bed for days on end both from collapsed energy and motivation. It can destroy the pleasure and rewards of living so that all activity feels like a painful chore at best. Finally, it can turn thoughts dangerously dark with so much hopelessness, helplessness and worthless that suicidal thinking emerges nearly with a sense of relief.

Again conversely, though experienced less often by most people, Manic Episodes can present with mild, moderate, severe and very severe intensity. During a sever episode, a person with manic symptoms is often sleeping little but maintaining very high levels of energy. They are often talking very quickly and sometimes laughing excessively and outside the context of humorous things. Given the very high levels of motivation and the reinforcement of pleasure in all activities, they often initiate an excessive number of activities – starting multiple projects with little awareness of the ability to balance or complete them. They frequently initiate conversations or relationship in an open or disinhibited style very unusual for to their character. With elevated thought patterns, they might believe they have a unique or special purpose, and they are convinced that all their activities will be successful and rewarding. Give the excessive energy, motivation, pleasure and elevated sense of self and success, people in manic states will often engage in behavior patterns much riskier than typical – spending money well beyond their mean, unusually disinhibited sexual decision, reckless driving, shop lifting.

I hope it’s useful to review the way mood symptoms fluctuate along these two spectrums, because like all health care conditions, we are best off when we accurately identify what these behaviors are – symptoms. Mood symptoms are not moral challenges, personality traits or unconsciously desired behaviors. Mood symptoms are symptoms, and fortunately, there are many very effective treatments for all symptoms along both spectrums. Please know if you or a loved one or a client is experiencing any degree of Bipolar mood problems, there will be many ways to help and cope, and experience the satisfaction of effectively treating a behavioral health care condition.

 

Return to blog >

 

By: Zachary Pettibone, MD
Staff Psychiatrist, Lindner Center of HOPE
Assistant Professor of Clinical Psychiatry
University of Cincinnati

Bipolar depression has been gaining attention recently in popular culture and the profession of psychiatry. New medications have emerged to manage this often difficult to treat illness. Bipolar depression denotes a specific type of “depression,” a distinction often unknown to patients seeking treatment and not always appreciated by clinicians. One of the most difficult challenges in clinical psychiatry is characterizing a depressive episode as falling within the diagnosis of major depressive disorder (MDD, sometimes referred to as “unipolar depression”) or bipolar disorder (BP, occasionally referred to as “manic depression”). The distinction is of critical importance because pharmacotherapy for BP and MDD differ significantly. Misdiagnosis and subsequent mismanagement can lead to years of suffering from adverse medication side effects and inadequate stabilization of symptoms.

A major depressive episode, as defined by the American Psychiatric Association (APA), is “a period of at least two weeks in which a person has at least five of the following symptoms (including at least one of the first two symptoms): intense sadness or despair, loss of interest in activities the person once enjoyed, feelings of worthlessness or guilt, fatigue, increased or decreased sleep, increased or decreased appetite, restlessness (e.g., pacing) or slowed speech or movement, difficulty concentrating, and frequent thoughts of death or suicide.” This same definition is used for depressive episodes in both MDD and BP. Despite the diagnostic overlap, depressive episodes in MDD and BP are considered distinct entities with their own indicated treatments. This leads to the question: given the same diagnostic criteria, how does one distinguish MDD depression from BP depression?

The primary differentiating factor is the presence or absence of manic or hypomanic episodes. A manic episode is defined by the APA as “a period of at least one week when a person is extremely high-spirited or irritable most of the day for most days, possesses more energy than usual, and experiences at least three of the following changes in behavior: decreased need for sleep (e.g., feeling energetic despite significantly less sleep than usual), increased or faster speech, uncontrollable racing thoughts or quickly changing ideas or topics when speaking, distractibility, increased activity (e.g., restlessness, working on several projects at once), and increased risky behavior (e.g., reckless driving, spending sprees).” These behaviors must represent a change from the person’s usual behavior and be clear to friends and family and cause significant impairments in occupational and social functioning that frequently necessitate psychiatric hospitalization. Hypomania is a milder form of mania that lasts for a shorter period and does not disrupt daily functioning.

If such an episode has occurred, the diagnosis is clear: BP depression. However, depressive episodes pre-date manic/hypomanic episodes in most cases of BP. In some instances, previous manic/hypomanic episodes were overlooked. And in other cases, a patient may mistake symptoms of mania for other psychiatric diagnoses, such as ADHD, borderline personality disorder, anxiety, and drug abuse. Further complicating the picture is the fact that these illnesses commonly coexist with BP.

Laboratory tests and imaging modalities have yet to be developed for diagnosing MDD and BP. The diagnosis is based on clinical interviews and observations. There are validated self-report symptom questionnaires that can help diagnose and facilitate discussion among patients and mental health providers. One frequently used instrument is the Mood Disorder Questionnaire (MDQ). Collateral information from friends, family, and coworkers can be invaluable for supplementing a patient’s recollection of symptoms and behaviors.

Some studies suggest there may be subtle differences in the way depression manifests clinically in BP and MDD, such as more severe motor slowing and predominance of atypical symptoms (hypersomnia and increased appetite) in BP depression. Other clues from a patient’s history may help point to BP over MDD, such as early onset of depressive episodes, the presence of psychotic features, severe and frequent depressive episodes, high anxiety, episodes that have not responded to traditional antidepressant therapy, substance misuse, a history of ADHD, and suicidality. No single feature is diagnostic, however. Each piece of the history must be considered in the context of the entire presentation.

The medications used to treat each type of depression are very different, and often ineffective or even harmful if used for the incorrect type of depression. For someone seeking treatment for undifferentiated depression with no history of mania or other strong indications of BP, an antidepressant medication is typically recommended. Commonly used antidepressants include selective serotonin reuptake inhibitors (SSRIs) and selective serotonin norepinephrine reuptake inhibitors (SNRIs). Other antidepressants with different mechanisms of action may also be used to treat MDD. There is debate among experts about the efficacy and safety of antidepressants for treating BP depression, and while antidepressants may have a place in the treatment of BP depression, the risk of precipitating manic episodes, causing rapid cycling mood episodes, and inadequately treating the illness often relegate antidepressants for use in MDD.

Medications indicated for the treatment of BP depression include second-generation antipsychotics and mood stabilizers. Lithium and the anticonvulsants lamotrigine (Lamictal) and valproate (Depakote) are mood stabilizers that are sometimes used “off label” to treat bipolar depression. Second-generation antipsychotics approved for BP depression are cariprazine (Vraylar), lumateperone (Caplyta), lurasidone (Latuda), olanzapine (Zyprexa) in combination with fluoxetine (Prozac), and quetiapine (Seroquel).

Differentiating BP depression from MDD depression represents a critical decision point in clinical practice. BP can go unrecognized or misdiagnosed as MDD for many years in a large proportion of patients seeking treatment for depressive episodes. Depression can be well managed when the appropriate treatment is chosen. Once a diagnosis is made and treatment is initiated, symptoms should be closely monitored, and the diagnosis reevaluated periodically to ensure effective treatment.

References:
Etain B, Lajnef M, Bellivier F, Mathieu F, Raust A, Cochet B, Gard S, M’Bailara K, Kahn JP, Elgrabli O, Cohen R, Jamain S, Vieta E, Leboyer M, Henry C. Clinical expression of bipolar disorder type I as a function of age and polarity at onset: convergent findings in samples from France and the United States. J Clin Psychiatry. 2012 Apr;73(4):e561-6. doi: 10.4088/JCP.10m06504. PMID: 22579163.

Fogelson, D., & Kagan, B. (2022). Bipolar spectrum disorder masquerading as treatment resistant unipolar depression. CNS Spectrums, 27(1), 4-6. doi:10.1017/S1092852920002047
Howland, M., & El Sehamy, A. (2021, January). What are bipolar disorders?. Psychiatry.org – What Are Bipolar Disorders? https://www.psychiatry.org/patients-families/bipolar-disorders/what-are-bipolar-disorders 

Mitchell, P., Frankland, A., Hadzi-Pavlovic, D., Roberts, G., Corry, J., Wright, A., . . . Breakspear, M. (2011). Comparison of depressive episodes in bipolar disorder and in major depressive disorder within bipolar disorder pedigrees. The British Journal of Psychiatry, 199(4), 303-309. doi:10.1192/bjp.bp.110.088823

Nestsiarovich, A., Reps, J.M., Matheny, M.E. et al. Predictors of diagnostic transition from major depressive disorder to bipolar disorder: a retrospective observational network study. Transl Psychiatry 11, 642 (2021).

Perlis RH, Brown E, Baker RW, Nierenberg AA. Clinical features of bipolar depression versus major depressive disorder in large multicenter trials. Am J Psychiatry. 2006 Feb;163(2):225-31. doi: 10.1176/appi.ajp.163.2.225. PMID: 16449475.

Swann AC, Geller B, Post RM, Altshuler L, Chang KD, Delbello MP, Reist C, Juster IA. Practical Clues to Early Recognition of Bipolar Disorder: A Primary Care Approach. Prim Care Companion J Clin Psychiatry. 2005;7(1):15-21. doi: 10.4088/pcc.v07n0103. PMID: 15841189; PMCID: PMC1076446.

Return to blog >

Fortunately, our culture has recently seen a gradual erosion of the stigma regarding emotional disorders, along with an increased understanding of such conditions. However, a less well-understood aspect of emotional disorders is the impact that they have on the cognitive functioning of those who are afflicted. Disorders such as Major Depression, Bipolar Disorder, Generalized Anxiety Disorder, Obsessive-Compulsive Disorder, and Schizophrenia all tend to interfere with one’s ability to access the full extent of their cognitive abilities, adding to the burden that these conditions create.

Regarding Major Depression, it is the one disorder that the DSM-V lists cognitive difficulties as one of the diagnostic criteria (diminished ability to think or concentrate, or indecisiveness, nearly every day). As a neuropsychologist, I routinely encounter patients who are all too aware that their depression impacts their ability to think clearly, to focus, and to recall everyday interactions. Part of the reason for this is that depression causes a reduction in processing speed, as well as the energy that it takes to attend to conversations and events. Difficulties with maintaining attention, and “keeping up” with things going on around them, these patients experience troubles recalling information, sometimes so profoundly that they begin to fear that they may have dementia. However, as their depression is more effectively treated, they regain full access to their cognitive skills and abilities.

Anxiety disorders also are accompanied by significant cognitive difficulties, for a couple of reasons. First, when the mind is anxious, most of the brain’s resources (blood flow, oxygen, glucose, etc.) are redirected to the emotional centers of the brain (the limbic system), and away from parts of our brain that mediate higher-level thinking and logic. Secondly, those who are anxious tend to be rather “internally-oriented” in their thinking, and so they are not as attentive to external events. In other words, because they become preoccupied with their fears and worries, the ordinary events of the external world can be largely overlooked. As a result, these ordinary events are not well-encoded into the memories of anxious patients, and therefore they cannot easily be recalled. As with depression, as anxiety becomes better managed, these cognitive issues largely resolve.

Two other diagnoses have profound implications for cognitive functioning. Bipolar disorder has a well-established pattern of cognitive difficulties, including diminished attention, verbal memory, and executive functioning abilities (planning, anticipating, problem-solving, emotional regulation, staying focused and attentive to personal goals, etc.) These difficulties, fortunately, are typically limited to times that these patients are actively experiencing a mood episode, whether it be depression or mania. Regarding those with schizophrenia, they experience similar cognitive difficulties. However, they often continue to experience such cognitive difficulties even when their symptoms of schizophrenia have been well-controlled with treatment. This is why the DSM-V lists “associated features” of schizophrenia specific to these difficulties, explaining that, “Cognitive deficits in schizophrenia are common and are strongly linked to vocational and functional impairments.”

Fortunately, over the past 20 years there have been treatments and interventions to address such cognitive difficulties. Cognitive Enhancement Therapy, or CET, has been developed and implemented for the mentally ill for whom cognitive problems are getting in the way of living independently, maintaining employment, and sustaining meaningful relationships. It has proven to be an effective means to address such difficulties, and for providing a much higher quality of life. It is anticipated that, as the benefits of CET become more evident to those working with the mentally ill, its positive impact will widen in both its breadth and depth.

Thomas A. Schweinberg, PsyD Staff Psychologist Lindner Center of HOPE

Return to blog >

 

Susan L. McElroy, MD

Lindner Center of HOPE, Chief Research Officer and Consultant to Eating Disorders Team

Borderline personality disorder (BPD) is a mental disorder consisting of a pervasive pattern of instability in regulation of emotions, impulses, interpersonal relationships, and self-image. Symptoms of BPD include frequent mood changes and excessive anger; feelings of worthlessness, insecurity, loneliness, and emptiness; periodic distortion of reality; and unhealthy social relationships.  Individuals with BPD are prone to self-harm (including suicidal ideation and behavior, self-cutting, and completed suicide), aggression, problematic alcohol and drug use, and other dangerous behaviors. The cause of BPD is unknown but thought to involve both genetic and environmental factors. Diagnosis is made clinically based on symptoms.

BPD is very common. It occurs in up to 5.9% of the general population and represents 15% to 29% of patients in psychiatric clinics and hospitals. Because the personality of children and adolescents is developing, the features of BPD do not become recognizable until late adolescence or early adulthood. Once the disorder appears, its course is often chronic. Though BPD is more common in women, a substantial number of men have the disorder as well.  There is a high comorbidity of BPD with other psychiatric disorders (approximately 85%), including anxiety disorders, mood disorders, impulse-control disorders, substance-use disorder, and eating disorders.

The present standard of treatment of BPD is psychotherapy, especially a form of psychotherapy called dialectical behavior therapy, to help individuals with tolerating distress and managing mood changes, impulses to self-harm, and relationships.  Most patients with BPD also receive psychiatric medication to target mood instability and excessive anger, impulsive and self-harming behavior, and cognitive and perceptual distortions. Small studies suggest medications that affect the dopamine and serotonin systems, particularly atypical (or second generation) antipsychotics (such as aripiprazole, quetiapine, and olanzapine), can be helpful for these symptoms. However, no medication has been approved by the United States Food and Drug Administration for the treatment of individuals with BPD.

The Research Institute at the Lindner Center of HOPE is participating in two important studies of one such medication, brexpiprazole, for treating BPD (clintrials.gov identifier NCT04100096 and NCT04186403) and is actively seeking individuals with BPD for participation. The first study is a 12-week, double-blind, placebo-controlled trial to evaluate the efficacy and safety of brexpiprazole for the treatment of individuals diagnosed with BPD. The second study is a six-month open-label trial of brexpiprazole in individuals who have completed the first study. (Open-label means all participants will receive brexpiprazole; no one receives placebo).

Otsuka Pharmaceutical Development and Commercialization, Inc., the manufacturers of brexpiprazole, is sponsoring the studies. Of note, brexpiprazole already has approval from the United States Food and Drug Administration for the treatment of schizophrenia and major depressive disorder (the later in combination with an antidepressant).

Please see the following links to get more information about the study:

https://clinicaltrials.gov/ct2/show/NCT04100096?term=Rexulti&cond=Borderline+Personality+Disorder&draw=1&rank=2

https://clinicaltrials.gov/ct2/show/NCT04186403?term=rexulti&draw=1&rank=8

https://lindnercenterofhope.org/research/

You may also contact Morgan Pond at [email protected]  or (513) 536-0704.

For further information on BPD:

https://www.nimh.nih.gov/health/topics/borderline-personality-disorder/index.shtml

Return to blog >

 

Trevor Steinhauser’s struggle with mental illness began at an early age, but thanks to receiving early help and support for his symptoms, Trevor is feeling better and is now four years sober.

Trevor and Tracy Cummings, MD, Medical Director of Inpatient and Partial Hospital Program Services at Lindner Center of HOPE, spoke with Local 12’s Liz Bonis about mental illness warning signs to watch for in children, such as anxiety and panic attacks.

Trevor credits the Lindner Center of HOPE for helping him overcome his own issues with mental illness and substance abuse. By employing a team approach and giving him a voice in his own treatment, Trevor says the Center was the first to help him learn coping skills for lifelong problems, such as depression and anxiety.

According to Dr. Cummings, behaviors that lead to addiction often present in a person’s youth.

“The reality is that, in any given year, one in five of us are experiencing mental illness. About half of those cases started before age 14, so a lot of people have been having symptoms for a long time. They’ve just figured out ways to either adapt to those or not talk about those,” Dr. Cummings said.

Lindner Center of HOPE has a comprehensive program that treats both substance abuse and co-occurring mental health disorders. Learn more about our Intensive Outpatient program here.

 

 

Watch the full story from Trevor and Dr. Cummings’ sit down with Liz Bonis interview on local12.com

 

Return to blog >

 

By Danielle J. Johnson, MD, FAPA
Lindner Center of HOPE, Chief of Adult Psychiatry

May is Maternal Mental Health Awareness Month.  One in five women will develop a maternal mental health disorder.  They are also referred to as perinatal mood and anxiety disorders (PMADs) to emphasize that women experience more than postpartum depression during pregnancy and after birth.  Women who have symptoms of PMADs might not seek help because of guilt, shame, or embarrassment for feeling something different than the expected norms of motherhood.  Awareness and education are important to reduce stigma so mothers and babies get the help they need.

PMADs can occur during pregnancy or up to one year after giving birth. The most common PMAD is the “baby blues”, affecting up to 80% of new mothers.  Symptoms include sudden mood swings, loneliness, sadness, crying spells, loss of appetite, problems sleeping, irritability, restlessness, and anxiety.  These symptoms are a normal adjustment to changes in hormones and resolve without treatment in two to three weeks.

About 10% of women experience depression during pregnancy and about 15% during the first year postpartum.  Feeling sad, hopeless, helpless, or worthless; fatigue, difficulty sleeping or sleeping too much, appetite changes, difficulty concentrating, crying, loss of interest or pleasure; lack of interest in, difficulty bonding with, or excessive anxiety about the baby; feelings of being a bad mother, and fear of harming the baby or self are symptoms of peripartum depression.  Risk factors include poverty, being a teen mother, advanced maternal age; personal or family history of depression, anxiety, or postpartum depression; premenstrual dysphoric disorder, inadequate support, financial stress, relationship stress; complications in pregnancy, birth or breastfeeding; a history of abuse or trauma, a major recent life event, birth of multiples, babies in neonatal intensive care, infertility treatments, thyroid imbalance, and diabetes.

Anxiety can occur alone, or with depression, in 10% of new mothers.  Symptoms include constant worry, racing thoughts, inability to sit still, changes in sleep or appetite, feeling that something bad is going to happen; and physical symptoms like dizziness, hot flashes, and nausea.  Some mothers may also have panic attacks with shortness of breath, chest pain, dizziness, a feeling of losing control, and numbness and tingling.  Risk factors are a personal or family history of anxiety, previous perinatal depression or anxiety, and thyroid imbalance.

Post-traumatic stress disorder (PTSD) can occur in up to 6% of mothers following a traumatic childbirth.  Possible traumas are prolapsed cord, unplanned C-section, use of vacuum extractor or forceps to deliver the baby, baby going to NICU; and feelings of powerlessness, poor communication and/or lack of support and reassurance during the delivery.  Women who have experienced a previous sexual trauma are also at a higher risk for developing postpartum PTSD.  Intrusive re-experiencing of the traumatic event, flashbacks or nightmares; avoidance of stimuli associated with the event; increased arousal (irritability, difficulty sleeping, hypervigilance, exaggerated startle response); anxiety and panic attacks, and feeling a sense of unreality and detachment are symptoms of PTSD.

Obsessive-compulsive disorder (OCD) can occur in 3% to 5% of new mothers.  Obsessions are persistent, repetitive thoughts or mental images, often related to the baby. Obsessions can be so bizarre or disturbing that they can be mistaken as psychosis.  Compulsions are repetitive acts performed to reduce obsessions.   Mothers are distressed by the obsessions which can lead to a fear of being left alone with the baby or hypervigilance in protecting the baby.  Mothers with postpartum OCD know that their thoughts are out of the ordinary and are unlikely to ever act on them.

Postpartum psychosis is the most severe of the PMADs.  It is often associated with an episode of bipolar disorder. It is rare, occurring in 1 to 2 per 1000 women.  The onset is abrupt, within 48 to 72 hours and up to two weeks after delivery. This is a psychiatric emergency, requiring immediate treatment.  Mothers may experience hallucinations (hearing voices or seeing things) and/or delusions (believing things that aren’t true.)  If psychosis occurs as part of a bipolar manic episode, there might be additional symptoms such as irritability, hyperactivity, decreased need for or inability to sleep, paranoia and suspiciousness, rapid mood swings, difficulty communicating, and confusion or memory loss. Risk factors are a personal or family history of bipolar disorder or a psychotic disorder.  Most women with postpartum psychosis do not have violent delusions but there is an up to 5% rate of infanticide or suicide due to acting on delusions or having irrational judgement.

PMADs are the most common complication of pregnancy and childbirth.  They are treatable with psychotherapy and/or medication and early intervention provides relief for the mother and ensures the baby’s wellbeing.

Return to blog >

On October 28, 2015, Dr. Elizabeth Wassenaar, Lindner Center of HOPE Psychiatrist and Williams House Medical Director, joined Lon Woodbury on the Woodbury Report radio show.  Their discussion focused on outlining the benefits of a residential assessment for mental health concerns in adolescents.

Click here to listen.

Return to blog >

By Paul E. Keck, Jr., MD
President-CEO, Lindner Center of HOPE
Frances & Craig Lindner Professor & Executive Vice Chair
Department of Psychiatry & Behavioral Neuroscience
University of Cincinnati College of Medicine
 

Bipolar disorder is common and recurrent psychiatric illness associated with high rates of morbidity, disability and mortality. In the United States, the 12-month prevalence rate of bipolar I and II disorder is estimated at 2.6%. Bipolar I disorder is distinguished from major depressive disorder by the occurrence of manic episodes. Bipolar II disorder is distinguished from major depressive disorder by the occurrence of mild manic symptoms, and depressive episodes tend to predominate the course of illness.

Symptoms of mania include: abnormally and persistently elevated, expansive or irritable mood, excessive energy or activity, psychomotor agitation, decreased need for sleep, grandiosity, excessive speech, racing thoughts, distractibility, impulsivity, and poor insight. Manic episodes often constitute a medical emergency requiring hospital admission and severe depressive episodes similarly pose a risk of suicide and need for hospital care.

Bipolar disorder frequently presents early in an individual’s life, frequently between the ages of 16-24, and often the initial mood episode may be depression, further complicating the diagnosis. Bipolar disorder is highly heritable. Clinical predictors of bipolar disorder include a family history of a first degree relative with bipolar disorder and early age of onset of depression.

Fortunately, there have been substantial advances in the evidence-based treatments of bipolar disorder over the past several decades. The goals of treatment of acute mood episodes (manic, mixed, and depressive) are rapid, complete remission in a safe environment. The goals of long-term or maintenance treatment are prevention of further episodes, eradication of sub-syndromal symptoms, and optimizing quality of life and function.

The treatment of bipolar disorder is often complicated because of a number of factors. First, bipolar disorder is the single psychiatric illness associated with the greatest degree of comorbidity. For example, addictions, anxiety disorders, eating disorders, migraine, overweight and obesity, and diabetes are all more common in people with bipolar disorder than in the general population. Thus, treatment recommendations often require addressing not only the symptoms of bipolar disorder itself, but also concurrently addressing comorbid illnesses.

Second, within the realm of bipolar disorder itself, although classified as a mood disorder, this illness is also fraught with symptoms in behavior, cognition and perception, as well as insight.

Third, treatment is further complicated by the diversity of illness presentation. For example, there are often substantial differences among patients in the pattern, frequency, and severity of mood episodes, the presence of absence of psychosis, and in acute or chronic psychosocial and other environmental stressors. Further, some medications have particular efficacy in one phase of illness but not in another, and some may actually increase the likelihood of precipitating a reciprocal mood episode.

Evidence-based treatment of bipolar disorder is generally categorized by treatment of acute mood episodes and maintenance treatment, designed to prevent recurrent symptoms and episodes. Medications with evidence of efficacy in the treatment of manic episodes include: first- and second-generation antipsychotic drugs, lithium, valproate, and carbamazepine. Medications with evidence of efficacy in the treatment of bipolar depressive episodes include: olanzapine, olanzapine-fluoxetine combination, lithium, quetiapine and lurasidone. The co-administration of unimodal antidepressants in the treatment of bipolar depression remains controversial, although clinically a substantial subgroup of people with bipolar depression appears to need such agents.

Within the many types of antidepressants, some data indicate that SNRI’s may pose a greater switch risk. Medications with evidence of efficacy in maintenance treatment include: lithium, olanzapine, lamotrigine, aripiprazole, quetiapine, and long-acting injectable paloperidone. Many people with bipolar disorder require a combination of medications to achieve and sustain euthymia. It is also important to recognize that certain medications that were once thought promising for bipolar disorder have not been proven to have efficacy in any phase of the illness. These include, for example, topiramate, gabapentin, and oxcarbazepine.

Although pharmacotherapy is the foundation of treatment of bipolar disorder, there are now evidence-based psychosocial treatments that improve outcome. These are primarily for the maintenance phase of treatment, have the greatest impact on depression and treatment adherence, and include: individual and group psychoeducation, individual interpersonal and social rhythm therapy, cognitive-behavioral therapy, and family-focused treatment.

Resources

Keck PE, Jr, McElroy SL. Pharmacological treatments for bipolar disorder. Nathan PE, Gorman JM, eds. A Guide to Treatments That Work, 3rd edition, Oxford, NY, 2007, pp. 323-350.

Miklowitz DJ, Craighead WE, Psychosocial treatments for bipolar disorder. Nathan PE, Gorman JM, eds. A Guide to Treatments That Work, 3rd edition, Oxford, NT, 2007, pp. 309-322.

http://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml

Return to news >

REELABILITIES LOGO with hashtag

Festival Runs February 27th – March 7th, 2015

ReelAbilities is the largest national film festival dedicated to celebrating the lives, stories and art of people with disabilities.

Lindner Center of HOPE is proud to be a part of the 2015 ReelAbilities Film Festival organized by Living Arrangements for the Developmentally Disabled (LADD) which runs February 27th through March 7th 2015 in Greater Cincinnati. For the first year, ReelAbilities is including films touching on the subject of mental illness in the festival. For more information about the film festival, click here.

Lindner Center of HOPE is the Host Agency for HERE ONE DAY, a documentary that chronicles filmmaker Kathy Leichter’s move back into her childhood home after her mother’s suicide. The film will be shown at Kenwood Theater on Monday, March 2, 2015 at 7:30 p.m.

Leichter discovered a hidden box of audiotapes. Sixteen years passed before she had the courage to delve into this trove, unearthing details that her mother had kept secret for so long. HERE ONE DAY is a visually arresting, emotionally candid film about a woman coping with mental illness, her relationships with her family, and the ripple effects of her suicide on those she loved. Click here to view trailer.

Following the film, Lindner Center of HOPE will host a brief panel discussion with question and answers with the audience. Jessica Noll, WCPO, will emcee the discussion.

Panel members will include:

Kathy Leichter, HERE ONE DAY filmmaker

John M. Hawkins, MD, Lindner Center of HOPE, Chief of Psychiatry, Deputy Chief Research Officer, Director TMS Services, University of Cincinnati College of Medicine, Adjunct Associate Clinical Professor of Psychiatry

Charles F. Brady, PhD, ABPP, Lindner Center of HOPE, Staff Psychologist, OCD/CBT Psychotherapist, Professor the University of Cincinnati’s Department of Psychiatry

Angela Ostholthoff, CPRP, CPS, Training Coordinator for The Recovery Center of Hamilton County

Shirley Benoit, Patient/Advocate

Here One Day imageHERE ONE DAY

Kathy Leichter / USA / English / 2012 /

76 min. / Documentary / Open Captions

Monday

March 2nd, 2015 – 7:30pm

at the Kenwood Theater

Benefiting the Lindner Center of HOPE,  Buy Tickets Here.