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Treating Bipolar Disorder in the Primary Care Setting

Treating Bipolar Disorder in the Primary Care Setting . Presented by: Jonathan Betlinski, MD. Date: 10/16/2014. Disclosures and Learning Objectives. Learning Objectives Be able to name three treatments for mania/hypomania Be able to name three treatments for bipolar depression

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Treating Bipolar Disorder in the Primary Care Setting

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  1. Treating Bipolar Disorder in the Primary Care Setting Presented by: Jonathan Betlinski, MD Date: 10/16/2014

  2. Disclosures and Learning Objectives • Learning Objectives • Be able to name three treatments for mania/hypomania • Be able to name three treatments for bipolar depression • Be able to name three lifestyle treatments for bipolar disorder Disclosures: Dr. Jonathan Betlinski has nothing to disclose.

  3. Treating Bipolar Disorder in Primary Care • Review screening for Bipolar Disorder • Review treatments for mania/hypomania • Review treatments for bipolar depression • Review strategies for maintenance • Next Week's Topic

  4. Manic Episode Distractibility Involvement in pleasurable activities that have a high potential for painful consequences Grandiosity or inflated self-esteem Flight of ideas or subjective experience that thoughts are racing Activity increase or psychomotor agitation Sleep need decreased Talkative or pressure to keep talking http://www.ncbi.nlm.nih.gov/books/NBK64063/

  5. Mania vs. Hypomania Mania Lasts 7 days OR requires hospitalization OR includes psychosis AND causes significant impairment Hypomania Only has to last 4 days Does not cause significant impairment http://www.ncbi.nlm.nih.gov/books/NBK64063/

  6. The Bipolar Disorders Bipolar I Disorder Manic Episode(s) +- depression Bipolar II Disorder Recurrent Major Depressive Episodes with Hypomanic episodes Cyclothymia Chronic cycling between hypomania and dysthymia Bipolar Disorder NOS http://www.ncbi.nlm.nih.gov/books/NBK64063/

  7. Screening Tools – MDQ and CIDI 3.0 MDQ 15 Question written survey Score of 7 + Yes + Moderate/Severe = Specificity 0.93 http://www.integration.samhsa.gov/images/res/MDQ.pdf CIDI 3.0 12 Question Interview Score of 9 = 80% risk http://www.integration.samhsa.gov/images/res/STABLE_toolkit.pdf

  8. Treating Mania/Hypomania Stop antidepressants (or inciting agents) Use a mood stabilizer first Lithium, Valproate Carbemazepine, Oxcarbazepine If psychosis occurs, use an antipsychotic Olanzapine, Risperidone, Asenapine? Aripiprazole, Ziprasidone, Quetiapine Consider short term use of a benzo http://www.jhasim.com/files/articlefiles/pdf/ASM_6_6A_p442_458_R1.pdf http://psychiatryonline.org/content.aspx?bookid=28&sectionid=1682557

  9. Treating Depression in Bipolar Disorder Start with lithium or lamotrigine Quetiapine, olanzapine/fluoxetine “Antidepressant monotherapy is not recommended.” Add lamotrigine or bupropion if needed Paroxetine, Venlafaxine. Pramipexole? ECT if severely depressed or pregnant CBT and Behavioral Activation, too! http://psychiatryonline.org/content.aspx?bookid=28&sectionid=1682557 http://www.jhasim.com/files/articlefiles/pdf/ASM_6_6A_p442_458_R1.pdf

  10. Rapid Cycling Bipolar Disorder 4 or more mood episodes per year At least partial remission for 2 months OR switch to episode of opposite polarity Identify and treat comorbid contributors Hypothyroidism or drug/alcohol use Taper contributing medications Lithium, Valproate or Lamotrigine Combination treatment often required http://psychiatryonline.org/content.aspx?bookid=28&sectionid=1669577 http://www.jhasim.com/files/articlefiles/pdf/ASM_6_6A_p442_458_R1.pdf

  11. Maintenance for Bipolar Disorder Continue agent that helped in acute phase Taper benzodiazepines Taper antipsychotics when mood stable Lamotrigine may help ward off depression Lithium may be better at warding off mania Valproate, Olanzapine, Carbemazepine, Oxcarbazapine also evidence-based http://psychiatryonline.org/content.aspx?bookid=28&sectionid=1669577 http://psychiatryonline.org/content.aspx?bookid=28&sectionid=1682557 http://www.jhasim.com/files/articlefiles/pdf/ASM_6_6A_p442_458_R1.pdf

  12. Non-Pharmacologic Maintenance Family Focused Therapy Fewer relapses and longer intervals Cognitive Therapy Fewer/shorter episodes and admissions Psychosocial interventions Extends remission, decreases recurrence Light/sleep management Omega-3 Fatty Acids http://www.psycheducation.org/depression/meds/Omega-3.htm http://psychiatryonline.org/content.aspx?bookid=28&sectionid=1682557 http://www.jhasim.com/files/articlefiles/pdf/ASM_6_6A_p442_458_R1.pdf

  13. Lifestyle Changes for Bipolar Disorder Eliminate alcohol, caffeine, and nicotine Eliminate illicit substances (+cannabis) Regular exercise Balanced diet (Omega-3 Fatty Acids) Mood charts Avoid Blue Light (especially night lights) Sleep Hygiene! http://www.psycheducation.org/depression/LightDark.htm http://www.jhasim.com/files/articlefiles/pdf/ASM_6_6A_p442_458_R1.pdf

  14. Additional Resources Johns Hopkins Advanced Studies in Medicine http://www.jhasim.com/files/articlefiles/pdf/ASM_6_6A_p442_458_R1.pdf http://www.jhasim.com/files/articlefiles/pdf/asm_6_6a_p430_441.pdf Harvard Pilgrim/UBH Clinical Practice Summary https://www.harvardpilgrim.org/pls/portal/docs/PAGE/PROVIDERS/MEDMGMT/GUIDELINES/BIPOLAR_CPG_PCP_0509.PDF Depression Bipolar Support Alliance http://www.dbsalliance.org http://www.dbsaoregon.org/ PsychEducation.org http://www.psycheducation.org/ Refer when needed http://ps.psychiatryonline.org/article.aspx?articleid=1861987 http://www.healthline.com/health-blogs/bipolar-bites/family-doctors-cannot-be-expected-treat-bipolar-disorder

  15. Summary PCPs can provide life-changing psychiatric and medical treatment for bipolar disorder! Recognizing Bipolar Disorder is much easier using the MDQ and/or CIDI 3.0 Pharmacology inevitably includes a mood stabilizer Lifestyle management is important http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2902189/

  16. The End! Next Week's Topic: Questions and Case Studies http://images.nationalgeographic.com/wpf/media-live/photos/000/812/overrides/your-shot-promo-untamed-wild-bird-sea_81205_100x75.jpg

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