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&sectionid=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&sectionid=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&sectionid=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&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

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&sectionid=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/

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