Treating Bipolar Disorder in the Primary Care Setting Presented by: Jonathan Betlinski, MD Date: 10/16/2014 1

Learning Objectives Disclosures and 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. 2

Review screening for Bipolar Disorder 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 3

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 Hypomania Mania vs. Hypomania 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/

Bipolar I Disorder Bipolar II Disorder Cyclothymia 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 NOS http://www.ncbi.nlm.nih.gov/books/NBK64063/

Screening Tools – MDQ and CIDI 3.0 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 Lithium, Valproate Carbemazepine, Oxcarbazepine If psychosis occurs, use an antipsychotic Olanzapine, Risperidone, Asenapine? Aripiprazole, Ziprasidone, Quetiapine Consider short term use of a benzo http://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 required http://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 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_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 Medicine http://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 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/ PsychEducation.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

Pharmacology inevitably includes a mood stabilizer 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/PMC2902189/

Questions and Case Studies The End! Next Week's Topic: Questions and Case Studies http://images.nationalgeographic.com/wpf/media-live/photos/000/812/overrides/your-shot-promo-untamed-wild-bird-sea_81205_100x75.jpg 16