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 Be able to name three lifestyle treatments for bipolar disorder Disclosures: Dr. Jonathan Betlinski has nothing to disclose.

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

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/NBK 64063/

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/NBK 64063/

The Bipolar Disorders • Bipolar I Disorder – • Bipolar II Disorder – • Recurrent Major Depressive Episodes with Hypomanic episodes Cyclothymia – • Manic Episode(s) +- depression Chronic cycling between hypomania and dysthymia Bipolar Disorder NOS http: //www. ncbi. nlm. nih. gov/books/NBK 64063/

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

Treating Mania/Hypomania • • Stop antidepressants (or inciting agents) Use a mood stabilizer first – – • If psychosis occurs, use an antipsychotic – – • Lithium, Valproate Carbemazepine, Oxcarbazepine Olanzapine, Risperidone, Asenapine? Aripiprazole, Ziprasidone, Quetiapine Consider short term use of a benzo http: //www. jhasim. com/files/articlefiles/pdf/ASM_6_6 A_p 442_458_R 1. pdf http: //psychiatryonline. org/content. aspx? bookid=28&sectionid=1682557

Treating Depression in Bipolar Disorder • Start with lithium or lamotrigine – • • “Antidepressant monotherapy is not recommended. ” Add lamotrigine or bupropion if needed – • • Quetiapine, olanzapine/fluoxetine 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_6 A_p 442_458_R 1. pdf

Rapid Cycling Bipolar Disorder • 4 or more mood episodes per year – – • Identify and treat comorbid contributors – • • • At least partial remission for 2 months OR switch to episode of opposite polarity 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_6 A_p 442_458_R 1. pdf

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_6 A_p 442_458_R 1. pdf

Non-Pharmacologic Maintenance • Family Focused Therapy – • Cognitive Therapy – • Fewer/shorter episodes and admissions Psychosocial interventions – • • Fewer relapses and longer intervals 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_6 A_p 442_458_R 1. pdf

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/Light. Dark. htm http: //www. jhasim. com/files/articlefiles/pdf/ASM_6_6 A_p 442_458_R 1. pdf

Additional Resources • Johns Hopkins Advanced Studies in Medicine http: //www. jhasim. com/files/articlefiles/pdf/ASM_6_6 A_p 442_458_R 1. pdf http: //www. jhasim. com/files/articlefiles/pdf/asm_6_6 a_p 430_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/ • Psych. Education. 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

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/PMC 2902189/

The End! Next Week's Topic: Questions and Case Studies http: //images. nationalgeographic. com/wpf/media-live/photos/000/812/overrides/your-shot-promo-untamedwild-bird-sea_81205_100 x 75. jpg