Bipolar Disorder – Diagnosis, Management and Treatment

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Bipolar Disorder Diagnosis, Management and
Treatment

• November 6, 2001
• Swedish Family Practice Residency

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Outline

• Prevalence of psychiatric disorders
• Prevalence and diagnosis of bipolar disorders
• Patient Information Handout - reading
• Physician Information Handout reading
• Break
• Case discussion 400 sharp
• More cases (if time)
• Who Wants to be a Psychiatrist? (if time)

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Overview of the Impact of Mental Illness in
Primary Care

• Prevalence of psychiatric disorders
• Prevalence of bipolar disorders
• One year prevalence vs. lifetime prevalence
• General population vs. clinic waiting room
• Multiple diagnoses/co-morbid conditions

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Common Psychiatric Disorders

• Anxiety Disorders 12.6
• Specific Phobias 3.2 (10-11.3)
• Social Phobia 2.7 (3-13)
• PTSD 2.6
• GAD 2 (5)
• OCD 2.1
• Panic Disorder 1.3
• Anxiety due to illness, medications, drugs, etc.
• In your office 25-35

• Mood Disorders 12.5
• Depression 5
• Major depressive disorder Minor depressive
  disorder PMDD
• Dysthymia 5.4
• Bipolar Disorders 2.1-2.7
• Depression due to illness, medications, drugs,
  bereavement, adjustment
• In your office 20-30

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Psychiatric Disorders in Children

• All Mental Disorders
• 12-15
• ADHD 2.2-9.9
• Conduct Disorder 1.5-5.5
• Separation Anxiety 2.3-9.2
• Specific Phobias 2.3-9.2

• Major Depressive Disorder 1 in young children to
  8.3 in adolescents
• Bulemia 1.1-4.2 of adolescents
• Anorexia .5-3.7 of adolescents

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Other Psychiatric Disorders

• Unexplained physical sympoms (25 of visits)
• Hypochondriasis 4-9
• Somatization disorder (.2-2)
• Conversion disorder
• Pain disorder
• Malingering
• Factitious disorder

• Schizophrenia 1
• Cognitive Disturbance
• Delirium
• Dementia 2.7 (20 over 85)
• Substance Abuse
• Alcohol (13)
• Other drugs (1)
• Sleep disturbance 30-40

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Prevalence of Psychiatric Disorders in Primary
Care Clinics

• 40 to 80!
• Are you missing something?

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Bipolar Disorder

• Bipolar Disorder I
• Lifetime 1.6
• Mean age of onset early 20s
• Clusters in families
• 15 suicide

• Bipolar Disorder II
• Lifetime 0.5
• Cyclothymia
• Lifetime .4-1

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Bipolar I Disorder

• Manic episode lasts over one week or requires
  hospitalization
• Not secondary to substance abuse
• Causes impairment of normal functioning

• Mania grandiosity, increased self-esteem,
  decreased need for sleep, flight of ideas,
  agitation, excessive involvement in pleasurable
  activity -buying spree, sex, business investments
  

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Bipolar I Disorder

• May have psychotic symptoms when manic or
  depressed
• No psychotic symptoms when stable
• (distinguishes from schizophrenia or
  schizoaffective disorder)

• Major depressive episodes often precede or follow
  manic episodes
• 80 will have multiple episodes
• Kindling effect of multiple episodes

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Mixed Episode

• Symptoms of both mania and major depression
• Symptoms may alternate during the day
• Often more disabling and difficult to treat

• Excitable or agitated but irritable and
  depressed instead of feeling euphoric

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Rapid Cycling

• At least four episodes a year of manic,
  hypomanic, mixed or depressive episodes
• Present in 5 to 15 of patients with bipolar
  disorder

• May be triggered by taking antidepressants for
  depressive episodes

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Bipolar II Disorder

• Hypomanic episode lasting 4 days or longer not
  requiring hospitalization
• Not secondary to substance abuse
• No impairment of normal functioning

• Hypomania - elevated, expansive or irritable
  mood but not as severe as mania
• Major depressive episodes often precede or follow
  hypomanic episodes

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Cyclothymia

• Chronic mood disturbance with many periods of
  hypomania and depressed mood
• Episodes are generally shorter than in bipolar I
  or II

• No episodes meet criteria for mania or major
  depressive disorder
• 15 to 50 risk of developing bipolar I or II
  disorder

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Case 1

• A twenty-six year old woman presents to your
  Saturday clinic. She just moved to Seattle from
  the Midwest and is living in her car. She is
  somewhat unkempt, tense, hyper-vigilant and
  paranoid. She has not eaten in several days and
  has only slept for a few hours a night over the
  past several weeks.

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• Read Patient Information
• Read Physician Information
• Take a Break
• Be back by 400 to discuss cases and play Who
  Wants to be a Psychiatrist?

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Case 2

• Forty-nine year old male who has been kicked out
  of his mothers clinic because of bizarre
  behavior. He is taking lithium, depakote and
  carbamazepine. He is alert and oriented but
  indeed is behaving rather strangely in your
  clinic, threatening the front desk staff with
  push-pins and crawling on the floor. What would
  you like to know about his past medical history?

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Case 2

• The patients tells you he has been in the
  hospital at least twice a year for the past 20
  years and with a weird twinkle in his eye, he
  challenges you to see if you can keep him out of
  the hospital.

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Case 2

• You increase the doses of all three mood
  stabilizers to therapeutic blood levels but
  despite complete compliance with all his
  medications, the patient is found squirting
  everyone in his neighborhood with his hose and
  doing the same in the neighborhood around your
  clinic. The police bring him to you to take care
  of.

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Case 2

• After being hospitalized and sedated for several
  days, the patient is discharged back to your care
  on clonazepam, haldol and valproate. He is
  relatively stable for a few weeks and then
  becomes very depressed and stops his haldol and
  valproate.

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Case 2

• What medications might you try now?
• The patient does well on your new regime for
  several months but them becomes very depressed.
• What medication might you try now?
• The patient does well on his new medication
  regime for 6 years with no psychiatric
  hospitalizations.

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Case 3

• A thirty-three year old woman presents to your
  office with a history of sexual abuse as a
  teenager and forced hospitalization with over 12
  ECT treatments after telling her mother that her
  father was the abuser. She has only vague
  memories of either having had an abortion or
  delivering a child during her several months of
  hospitalization.

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Case 3

• The patient has tried to get her sisters to
  admit to similar abuse during their childhood but
  her whole family, including her parents think she
  is crazy and treat her like an outcast. The
  patient has been in and out of the hospital for
  twenty years with episodes of paranoia and
  delusions. Between hospitalizations she is free
  of delusional thinking and has managed to
  graduate from high school and has finished
  several years of college.

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Case 3

• What possible diagnoses would you consider?
• What medications would you consider?

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Case 3

• You manage the patient with various
  mood-stabilizers but she is reluctant to take
  them for long because of side-effects. Despite
  your best work in trying to convince her that she
  will need to take medications for the rest of her
  life, she is reluctant to take anything for very
  long and ends up in the hospital every four to
  six months.

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Case 3

• After her fourth hospitalization she finally
  accepts the fact that she would do better if she
  would take her medications and does so until she
  gets acutely toxic on lithium after being given a
  shot of toradol in the ER and getting rashes from
  both valproate and carbamazepine. What
  medications would you try now?

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Case 3

• On your new medication regime your patient
  remains stable for 8 years with no
  hospitalizations. As long as she doesnt work
  more than 20 hours a week and has minimal contact
  with her family she does fine. When her mother
  visits or she visits her mother you see her in
  clinic once or twice a week as needed.

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Bipolar Pneumonic
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Live From SFM

• with
• Swedish FP Residents

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Who Wants to be a Psychiatrist?

• Forget the millionaires

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Fastest Hand 1 Rank in age from oldest to newest
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Rank in age from oldest to newest

• Prozac
• Zoloft
• Paxil
• Celexa

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How many bones are in the human body?
34
How many bones are in the human body?
35
What is an Apgar?
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What is an Apgar?
37
Which is the most prevalent psychiatric diagnosis
in the US
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What is the most prevalent psychiatric disorder
in the US?
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Which is the most common anxiety disorder in the
US?
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Which is the most common anxiety disorder in the
US?
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Which is the most common type of bipolar disorder?
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Which is the most common type of bipolar disorder?
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What is the least effective mood stablizer for
BPD?
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What is the least effective mood stabilizer for
BPD?
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Fastest Hand 3Put the following TV medical
dramas in order from oldest to newest

• Doogie Howser, MD
• Dr. Kildare
• E.R.
• St. Elsewhere

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Put the following TV medical dramas in order from
oldest to newest

• Dr. Kildare
• St. Elsewhere
• Doogie Houser, MD
• E.R.

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Which of the following is not an X-Mariner?
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Which of the following is not an X-Mariner?
49
Which disease is not caused by a virus?
50
Which disease is not caused by a virus?
51
Which cannot be put into regular solid waste
containers?
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Which cannot be put into regular solid waste
containers?
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Which of the following medications might be used
to treat patients with bipolar depression?
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Which of the following medications might be used
to treat patients with bipolar depression?
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Which of the following antidepressants is most
likely to trigger a manic switch in a patient
with bipolar depression?
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Which of the following antidepressants is most
likely to trigger a manic switch in a patient
with bipolar depression?
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Which of the following are not used to treat
resistent depression in patients with BPD?
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Which of the following are not used to treat
resistent depression in patients with BPD?
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The End

• Thank You