Bipolar Disorder – Diagnosis, Management and Treatment

1. Bipolar Disorder – Diagnosis, Management and Treatment November 6, 2001 Swedish Family Practice Residency

2. Outline • Prevalence of psychiatric disorders • Prevalence and diagnosis of bipolar disorders • Patient Information Handout - reading • Physician Information Handout – reading • Break • Case discussion – 4:00 sharp • More cases (if time) • Who Wants to be a Psychiatrist? (if time)

3. 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

4. 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% 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% Common Psychiatric Disorders

5. 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 Psychiatric Disorders in Children

6. 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% Other Psychiatric Disorders

7. Prevalence of Psychiatric Disorders in Primary Care Clinics 40% to 80%! Are you missing something?

8. Bipolar Disorder I Lifetime 1.6% Mean age of onset early 20’s Clusters in families 15% suicide Bipolar Disorder II Lifetime 0.5% Cyclothymia Lifetime .4-1% Bipolar Disorder

9. 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 Bipolar I Disorder

10. 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 Bipolar I Disorder

11. 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 Mixed Episode

12. 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 Rapid Cycling

13. 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 Bipolar II Disorder

14. 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 Cyclothymia

15. 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.

16. Read Patient Information • Read Physician Information • Take a Break • Be back by 4:00 to discuss cases and play “Who Wants to be a Psychiatrist?”

17. Case #2 Forty-nine year old male who has been kicked out of his mother’s 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?

18. 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.

19. 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.

20. 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.

21. 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.

22. 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.

23. 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.

24. Case #3 What possible diagnoses would you consider? What medications would you consider?

25. 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.

26. 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?

27. Case #3 On your new medication regime your patient remains stable for 8 years with no hospitalizations. As long as she doesn’t 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.

28. Bipolar Pneumonic

29. Live From SFM with Swedish FP Residents

30. Who Wants to be a Psychiatrist? Forget the millionaires

31. Fastest Hand #1Rank in age from oldest to newest

32. Rank in age from oldest to newest Prozac Zoloft Paxil Celexa

33. How many bones are in the human body?

34. How many bones are in the human body?

35. What is an Apgar?

36. What is an Apgar?

37. Which is the most prevalent psychiatric diagnosis in the US

38. What is the most prevalent psychiatric disorder in the US?

39. Which is the most common anxiety disorder in the US?

40. Which is the most common anxiety disorder in the US?

41. Which is the most common type of bipolar disorder?

42. Which is the most common type of bipolar disorder?

43. What is the least effective mood stablizer for BPD?

44. What is the least effective mood stabilizer for BPD?

45. Fastest Hand #3Put the following TV medical dramas in order from oldest to newest Doogie Howser, MD Dr. Kildare E.R. St. Elsewhere

46. Put the following TV medical dramas in order from oldest to newest Dr. Kildare St. Elsewhere Doogie Houser, MD E.R.

47. Which of the following is not an X-Mariner?

48. 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?