treating bipolar disorder in the primary care setting presented by: jonathan betlinski, md date:...
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Treating Bipolar Disorderin the Primary Care Setting
Presented by: Jonathan Betlinski, MDDate: 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/NBK64063/
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/
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 NOShttp://www.ncbi.nlm.nih.gov/books/NBK64063/
Screening Tools – MDQ and CIDI 3.0
• MDQ– 15 Question written survey– Score of 7 + Yes + Moderate/Severe
= Specificity 0.93http://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
– Lithium, Valproate– Carbemazepine, Oxcarbazepine
• If psychosis occurs, use an antipsychotic– Olanzapine, Risperidone, Asenapine?– Aripiprazole, Ziprasidone, Quetiapine
• Consider short term use of a benzohttp://www.jhasim.com/files/articlefiles/pdf/ASM_6_6A_p442_458_R1.pdf
http://psychiatryonline.org/content.aspx?bookid=28§ionid=1682557
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§ionid=1682557
http://www.jhasim.com/files/articlefiles/pdf/ASM_6_6A_p442_458_R1.pdf
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 requiredhttp://psychiatryonline.org/content.aspx?bookid=28§ionid=1669577
http://www.jhasim.com/files/articlefiles/pdf/ASM_6_6A_p442_458_R1.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§ionid=1669577
http://psychiatryonline.org/content.aspx?bookid=28§ionid=1682557
http://www.jhasim.com/files/articlefiles/pdf/ASM_6_6A_p442_458_R1.pdf
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 Acidshttp://www.psycheducation.org/depression/meds/Omega-3.htm
http://psychiatryonline.org/content.aspx?bookid=28§ionid=1682557
http://www.jhasim.com/files/articlefiles/pdf/ASM_6_6A_p442_458_R1.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/LightDark.htm
http://www.jhasim.com/files/articlefiles/pdf/ASM_6_6A_p442_458_R1.pdf
Additional Resources
• Johns Hopkins Advanced Studies in Medicinehttp://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 Summaryhttps://www.harvardpilgrim.org/pls/portal/docs/PAGE/PROVIDERS/MEDMGMT/GUIDELINES/BIPOLAR_CPG_PCP_0509.PDF
• Depression Bipolar Support Alliancehttp://www.dbsalliance.org
http://www.dbsaoregon.org/
• PsychEducation.orghttp://www.psycheducation.org/
• Refer when neededhttp://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 importanthttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC2902189/
The End!
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