what do primary care physicians really need to know about ... · mean age in unipolar depression is...

J. David Moore MD Clinical Assistant Professor, Associate Residency Training Director Department of Psychiatry and Behavioral Medicine Greenville Health System / University of South Carolina Greenville Greenville, SC

What Do Primary Care Physicians REALLY Need To Know About Bipolar Disorder

• No financial disclosures

• In the course of this presentation, medications will be discussed for off-label usage.

Disclosures

• Let’s make this subject as simple and useful as possible for a busy primary care setting

• How to rule out the false positives in bipolar screening/Screening Tools

• Differentiate bipolar disorder from other psychiatric disorders

• How to treat bipolar disorder in the short-term (<3 months)

• Know when to tell your patient that there is nothing else you can offer and when to refer and to whom to refer (psychiatry vs therapy)

Objectives

• “I have mood swings.”

• “I can’t control my mood. There’s nothing I can do about it… Yes, I try.”

• “I can get mad in a split second…I get upset over nothing.”

• “My Prozac was working, but then it just quit working.”

• “I’m up and down all the time. I must be rapid cycling.”

• “My mind is racing.”

• “It’s like I have a split personality.”

• “My {mom/dad/sibling/child} acts the same way as I do, and they have bipolar, so I do too, right?”

Your patient says WHAT?

• Men and women are affected equally

• Mean age of onset is 19yo-25yo Mean age in unipolar depression is roughly 25yo-35yo

• Cause ????? Unknown, but family and twin studies suggest genetic risk

• Lifetime risk of suicide is 15x higher in bipolar patients as compared to general population; roughly 15% will complete suicide

• About 1/3 of bipolar patients wait >10 years for accurate diagnosis

• Significant co-morbidities: 59% anxiety, 48% substance abuse, 9% ADHD, 8% eating disorders

Some general facts about Bipolar Disorder

• Prevalence (lifetime) in general population of schizophrenia = 1.1%

• Prevalence (lifetime) in general population of bipolar disorder=1-2% but it varies, depending whom you ask:

▫ Per DSM-5 = 0.6% for bipolar I

12 month prevalence for all types of bipolar = 1.8% ▫ Per NIMH = 3.9% for bipolar I

12 month prevalence for all types of bipolar = 2.6%

Graphic: NIMH

Schizophrenia vs Bipolar – Common?

• Prevalence (lifetime) in general population of bipolar disorder=1-2%

• Major depression= 12-15%

• Anxiety disorders=30%

• Borderline personality disorder=1.5%

• Adult ADHD=9%

Bipolar vs Other Disorders– Common?

• Bipolar I – has manias and depressions

• Bipolar II – has hypomanias and depressions

• Cyclothymia – has hypomanias and depressive symptoms

• Substance/Medication-induced Bipolar Disorder

• Bipolar due to Another Medical Condition

Comparing Apples to Apples: Let’s define ‘BIPOLAR’

• Head trauma, cerebral tumor, CVA

• Dementia

• Epilepsy

• Multiple sclerosis

• Parkinson’s disease

• Cushing’s, Addison’s

• Hypo- or Hyperthyroidism

• HIV, Mono, Influenza, Hepatitis

• Tertiary syphilis

• Toxoplasmosis

• Etc.

OTHER MEDICAL CONDITIONS

• Any illicit drug

• Indomethacin

• Stimulants

• Interferon, isoniazid

• Hydralazine, reserpine

• Corticosteroids

• Anticholinergics

• Levodopa

• Vincristine, vinblastine

• Etc.

SUBSTANCES/MEDICATIONS


• S - sleep changes

• I – interest less (anhedonia)

• G – guilt/worry

• E – energy less

• C – concentration less

• A – appetite changes

• P – psychomotor agitation/retardation

• S – suicidal thoughts

• S – sexual interest low

Let’s define ‘DEPRESSION’: “SIGECAPSS”

• MANIC = lasts 1 week or longer, of persistently elevated, expansive, or irritable mood AND increased goal-directed activity or energy AND has at least 3 symptoms(4 if mood is just irritable) of:

Inflated self-esteem or grandiosity

Markedly decreased need for sleep

More talkative or pressure to keep talking

Flight of ideas or racing thoughts

Distractibility

Increase in psychomotor activity

Excessive involvement in activities with high potential for painful consequences, such as promiscuity, foolish business investments, unrestrained spending sprees

Comparing Apples to Apples: Let’s define ‘MANIA’

• D – distractibility

• I – indiscretion, irresponsibility

• G – grandiosity

• F – flight of ideas/racing thoughts

• A – activity increased

• S – sleep decreased

• T - talkativeness

Let’s define ‘MANIA’: “DIGFAST”

• HYPOMANIC = lasts at least 4 consecutive days, of persistently elevated, expansive, or irritable mood AND increased goal-directed activity or energy AND has at least 3 symptoms (4 if mood is just irritable) of:

Inflated self-esteem or grandiosity

Markedly decreased need for sleep

More talkative or pressure to keep talking

Flight of ideas or racing thoughts

Distractibility

Increase in psychomotor activity

Excessive involvement in activities with high potential for painful consequences, such as promiscuity, foolish business investments, unrestrained spending sprees

Comparing Apples to Apples: Let’s define ‘HYPOMANIA’

• MUST have had a manic or hypomanic episode; but there does NOT have to have been a major depressive episode for Bipolar I (Bipolar II requires both hypomania and depression)

• Mania and hypomania have almost the same criteria, with the main differences in:

1. length of episode (4+ days vs 7+ days)

2. marked impairment (or not) in social or

occupational functioning

3. if psychosis present, then it is NOT hypomania


Yes, it does exist, and here’s when it does: Can occur in Bipolar I or Bipolar II

Presence of at least 4 mood episodes (mania, hypomania, and depression) over past 12 months AND: Episodes are demarcated by full or partial remissions of 2 months between

switches

Must include a full switch to opposite polarity at some point

Must meet all duration and symptom number criteria for each episode

Comparing Apples to Apples: ‘RAPID CYCLING?’

• The validity of it……

• 3 parts to it: ▫ 1. symptom checklist

▫ 2. “have the symptoms happened during the same period of time?”

▫ 3. “have the symptoms caused moderate to severe problems with work, family, money or legal troubles, arguments or fighting?”

• Are you prepared to ask many more questions?

Screening Tool: The MDQ (Mood Disorder Questionnaire)

“The Mood Disorders Questionnaire screens for bipolar disorder. This screen was positive, suggesting that bipolar disorder is present. He is irritable. A decrease in sleep has occurred. He has been over-talkative. He describes racing thoughts. He is distractible. He has an increase in sociability and libido.”

- this is exact quote from a medical record, in an initial evaluation by a psychiatrist, to justify the diagnosis of a bipolar disorder

Psychiatrists don’t get it right either

• Prevalence prior to adolescence:

No great studies or data, but likely <1%

For bipolar 1 diagnosis, must meet criteria for mania, just like an adult.

IRRITABILITY alone does not = bipolar disorder!

Consider DISRUPTIVE MOOD DYSREGULATION DISORDER

Bipolar in children and adolescents

• Core feature is chronic, persistent irritability in association with severe temper outbursts ▫ Inconsistent with developmental age

▫ Occurs 3 or more times per month

▫ Present for >12 months

▫ Occurs in at least 2 settings (at home, at school, with peers)

▫ Not before 6yo, and can be made up to 18yo; symptoms have to have been present by 10yo

DISRUPTIVE MOOD DYSREGULATION DISORDER

• Refer out to psychiatry Are there any psychiatrists in my area?

Is my patient willing to go see THAT kind of doctor?

Do they take insurance? Can my patient afford it?

How about a therapist? If so, what are you going to suggest for medications?

What’s the waiting time to see a mental health provider?

• Treatment Therapy

Medications

Treatment Options in the Primary Care Setting

• What kind of patient is this? Age, child bearing age, fall risk, history of being compliant vs non-compliant

• What are the patient’s other medical issues? Renal issues, hepatic impairments, dementia, substance use disorders, cardiac

issues

• What other medications are they on? NSAID’s, steroids, inhalers, stimulants

Options for Medications

• OLANZAPINE/FLUOXETINE

• QUETIAPINE (and XR)

• LURASIDONE

FOR ACUTE DEPRESSION IN BIPOLAR

• LITHIUM

• CHLORPROMAZINE

• DIVALPROEX (and ER)

• OLANZAPINE

• RISPERIDONE

• QUETIAPINE (and XR)

• ZIPRASIDONE

• ARIPIPRAZOLE

• CARBAMAZEPINE ER

• ASENAPINE

FOR ACUTE MANIA IN BIPOLAR

The medications FDA-approved in bipolar disorder

• LITHIUM

• LAMOTRIGINE

• OLANZAPINE

• ARIPIPRAZOLE

• QUETIAPINE (and XR is adjunct only)

• RISPERIDONE LAI (CONSTA)

• ZIPRASIDONE (adjunct only)

FOR MAINTENANCE IN BIPOLAR

The medications FDA-approved in bipolar disorder

• LITHIUM has long been considered the first line care and is the gold standard for bipolar disorder.

• PROS: It works!

Defined serum blood level for efficacy (0.8-1.2)

1 of only 2 proven medications to prevent suicide.

“A little lithium is better than no lithium.”

Inexpensive (the medicine itself)

Let’s talk treatment

• LITHIUM has long been considered the first line care and is the gold standard for bipolar disorder.

• CONS: Need lab work-ups intermittently (can be expensive) Other entities affect the blood level (dehydration, NSAID’s, diuretics) Nuisance side effects: diarrhea, weight gain, tremor, acne Other side effects: hypothyroidism, hyperparathyroidism, diabetes insipidus, decreased Cr clearance with long term use, prolong QTc, pregnancy risks, leukocytosis


LAMOTRIGINE (LAMICTAL)

• PROS: few side effects

proven efficacy in bipolar depression

no lab monitoring

• CONS: very small (<0.8%) risk of Steven-Johnson syndrome

takes 2 months to reach efficacy

monotherapy is not common

pregnancy risks ?????

OC’s decrease and valproate increases serum concentrations


VALPROATE (DEPAKOTE/DEPAKENE)

• PROS: has been around a long time, and many specialties use it and

are comfortable using it

very effective in manias/hypomanias

• CONS: requires lab monitoring

Nuisance side effects: hair loss, nausea/vomiting, weight gain

Other side effects: thrombocytopenia, pregnancy risks,

hepatic effects (increase liver enzymes)

not very effective in bipolar depression


CARBAMAZEPINE (TEGRETOL)

• PROS: has been around a long time, and many specialties use it and

are comfortable using it

effective in manias/hypomanias

• CONS: requires lab monitoring

Nuisance side effects: nausea/vomiting, rash, diplopia

Other side effects: leukopenia, pregnancy risks,

hepatic effects (increase liver enzymes)

not very effective in bipolar depression

induces own metabolism as well as many other meds


• All the others: SECOND GENERATION ANTI-PSYCHOTICS

ARIPIPRAZOLE (ABILIFY) • PROS: -no initial labs -less sedation, less weight gain, less endocrine effects, less prolactin issues -samples, coupons, etc. • CONS: -very expensive (but about to get cheaper) -akathesia/agitation (dose it in AM)



LURASIDONE (LATUDA)

• PROS: -no initial labs

-less sedation, much less weight gain, much less endocrine

effects, rare prolactin issues

-samples, coupons, etc.

• CONS: -very expensive (and not about to get cheaper anytime soon)

-nausea, akathesia, and sedation are main side effects

-dose? – it’s a wide range



QUETIAPINE (SEROQUEL/SEROQUEL XR)


-sedation can be a really good thing

-rare to no EPS/TD issues

• CONS: -relatively inexpensive

-weight gain and sedation are main side effects

-endocrine effects

-dose? – it’s a wide range



OLANZAPINE (ZYPREXA) or FLUOXETINE/OLANZEPINE (SYMBYAX)


-sedation can be a really good thing

• CONS: -weight gain and sedation can be more than you ever thought

possible

-endocrine effects are common with olanzapine

PLEASE NEVER PRESCRIBE SYMBYAX! Your referring ‘quality’ psychiatrist will thank you for never doing that.


• Some others:

▫ RISPERIDONE, ZIPRASIDONE, ASENAPINE, PALIPERIDONE


• All the others: FORGET ABOUT THEM!!!! (for bipolar treatment)

▫ GABAPENTIN, TOPIRAMATE, OXCARBAMAZEPINE, LEVETIRACETAM, etc.


1. Get rid of problematic medicines/polypharmacy, if you can stimulants, SNRI’s/tricyclics, non-useful psychiatric meds, reconsider non-

essential asthma meds or steroids

2. Get them to sleep Benzo’s (lorazepam, clonazepam), zolpidem, quetiapine, olanzapine

3. Think long-term and start LAMOTRIGINE, whether depressed or manic 25mg x2 weeks then 50mg x2weeks then 100mg x2weeks then 200mg qday

“I have 5 minutes. What should I do?”

4. Think short-term and start LITHIUM or SGA, if in mania/hypomania Lithium 300mg bid-tid – check level in 5-6 days at 12 hour trough and adjust;

you can also get baseline labs at that time OR,

Aripiprazole 5-10mg qam OR,

Quetiapine 100-300mg qhs OR,

If you are not yet starting lamotrigine, then valproate 500mg bid is also an option


5. Think short-term and start LITHIUM or ANTI-DEPRESSANT, if in depression

Lithium 300mg bid-tid – check level in 5-6 days at 12 hour trough and adjust; you can also get baseline labs here OR,

Any SSRI OR,

Bupropion XL 150mg qam (and wait 3-4 weeks and then decide if need to increase to 300mg qam if not better)


• Anxiety disorder Generalized anxiety disorder

Panic disorder

PTSD

OCD

• ADHD

• Substance Abuse/Intoxication/Withdrawal

• Unipolar Depression

• Borderline Personality Disorder

What else could this be psychiatrically?

• I – identity problem

• D – disordered affect

• E – empty feeling

• S – suicidal behavior/self-harm

• P – paranoia/dissociation

• A – abandonment terror

• I – impulsivity

• R – rage

• R – relationship instability

Borderline Personality Disorder : “I DESPAIRR”

2 locations:

701 Grove Rd and 1409 West Georgia Rd

Greenville, SC Simpsonville, SC

864-455-8431 (for both locations)

The Brownell Center at Greenville Health System USC School of Medicine Greenville

what do primary care physicians really need to know about ... · mean age in unipolar depression is...

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