Abdullah Al-Subaie F.R.C.P (C) Professor of Psychiatry

Cancer Epilepsy Fahr disease AIDS Medications (eg, antidepressants, baclofen, bromide, bromocriptine, captopril, cimetidine, corticosteroids, cyclosporine, disulfiram, hydralazine, isoniazid, levodopa, methylphenidate, metrizamide, procarbazine, procyclidine) Idiopathic Basal Ganglia Calcification personality and/or behavior, to psychosis and dementia

 Circadian rhythm desynchronization  Cyclothymic disorder  Oppositional defiant disorder (in children)  Substance abuse disorders (eg, with alcohol, amphetamines, cocaine, hallucinogens, opiates)

1. The basic principle remains, "do not miss a treatable medical cause for the mental status.“ 2. The condition necessitates use of a number of medications that require certain body systems to be working properly.

3. Because bipolar illness is a lifelong disorder, performing certain baseline studies is important. 4. A number of infections, especially chronic infections, can produce a presentation of depression in the patient.

 A complete blood count (CBC) with differential  To rule out anemia as a cause of depression.  Treatment, with certain anticonvulsants, may depress the bone marrow-hence the need to check the red blood cell (RBC) and white blood cell (WBC).  Lithium may cause a reversible increase in the WBC count.

 Erythrocyte sedimentation rate  To look for any underlying disease process such a lupus or an infection.  Fasting glucose  Atypical antipsychotics have been associated with weight gain and problems with blood glucose regulation in patients with diabetes.

 Electrolytes  Hyponatremia can manifest as a depression.  Treatment with lithium can lead to renal problems and electrolyte problems.  Low sodium levels can lead to higher lithium levels and lithium toxicity.  Lithium toxicity can lead to renal impairment.

Calcium – Hyperparathyroidism, produces depression. – Certain antidepressants, such as nortriptyline, affect the heart. Proteins – Low serum protein levels in depressed patients may be a result of not eating. – Low serum protein levels increase the availability of certain medications because these drugs have less protein to which to bind.

Thyroid hormones – To rule out hyperthyroidism (mania) and hypothyroidism (depression). – Treatment with lithium can cause hypothyroidism, which may also contribute to the rapid cycling of mood. Creatinine and blood urea nitrogen – Kidney failure can present as depression. – Treatment with lithium can affect urinary clearances, and serum creatinine and blood urea nitrogen (BUN) levels can increase.

 Substance and Alcohol Screening  Substance abuse can present as either mania or depression.  A number of patients with bipolar affective disorder also have a drug or alcohol addiction. Performing a substance screen helps make this dual diagnosis

Other Laboratory Tests – Urine copper level testing is used to rule out Wilson disease, which produces mental changes. This disease is a rare condition that is easily missed. Antinuclear antibody testing is used to rule out lupus. An HIV test because AIDS causes changes in mental status, including dementia and depression. A VDRL test may be indicated. Syphilis, especially in its later stage, alters mental status.

Magnetic Resonance Imaging – The total value of performing magnetic resonance imaging (MRI) in a patient with bipolar disorder remains unclear; however, – To establishes a baseline in such a chronic illness. – Some investigators report that patients with mania have hyperintensity in their temporal lobes. Electrocardiography – Many antidepressants, Lithtium and some of the antipsychotics, can affect the heart and cause conduction problems.

Electroencephalography – EEG provides a baseline and helps rule out any neurologic problems such as seizure disorder and brain tumor. – In electroconvulsive therapy (ECT), EEG monitoring during ECT is used to detect occurrence and duration of seizure. – Some EEG findings may indicate anticonvulsant effectiveness. Specifically, to valproate. – Some patients may have seizures when on medications, especially antidepressants. In addition, lithium can cause diffuse slowing.

The treatment is directly related to the phase of the episode and the severity of that phase. Most patients recover from the first manic episode, but their course beyond that is variable.

All patients with bipolar disorder need education, outpatient monitoring for both medications and psychotherapy. The schedule must be regular, with great flexibility if they need extra sessions. ECT may be needed but no surgical care is indicated for bipolar disorder

1. Danger to self  A depressed patient may have suicidal ideation, attempts or plans.  A person who is depressed enough to not eat might be at risk of death.  A person in extreme mania who foregoes sleep or food may be in a state of serious exhaustion.

2. Danger to others  A patient experiencing a severe depression may believe the world was so bleak that he planns to kill his children to spare them from the world’s misery.  A delusional patient having a manic episode may believes everyone was against him; he searches for a rifle in order to defend himself and to get them before they got him.

3. Total inability to function – Leaving such a person alone would be dangerous and not therapeutic. 4. Total loss of control 1. The patient’s behaviors may go totally out of control to harm themselves & others and may destroy their career & social position.

5. Medical conditions that warrant medication monitoring  Such as cardiac and renal conditions where the effects of the psychotropic medications can be monitored and observed closely.

1. Look at areas of stress and find ways to handle them : The stresses can stem from family or work, This is a form of psychotherapy. 2. Monitor and support the medication: Patients are ambivalent about their medications and they resent that they need them. The job is to address their feelings and allow them to continue with the medications.

3. Develop and maintain the therapeutic alliance: Over time, the strength of the alliance helps keep the patient’s symptoms at a minimum and helps the patient remain in the community. 4. Provide education (see Patient Education): Both the patient and the family need to be aware of the dangers of substance abuse, the situations that would lead to relapse, and the essential role of medications.

 Appropriate medication depends on the stage the patient is experiencing.  A number of drugs are indicated for an acute manic episode, primarily the antipsychotics, valproate, and benzodiazepines (eg, lorazepam, clonazepam)  The choice of agent depends on the presence of symptoms such as psychotic symptoms, agitation, aggression, and sleep disturbance.

Depressed Patient 1. In a patient with bipolar depression who is not on a mood-stabilizing agent, options include quetiapine or olanzapine, with carbamazepine and lamotrigine as alternatives. However, most clinicians use antidepressants and an antimanic agent in combination. 2. If the patient is already optimally treated with a mood-stabilizing agent such as lithium, an option would be lamotrigine.

2-Manic phase:  Lithium is the drug commonly used for prophylaxis and treatment of manic episodes.  S\E, hypothyroidism, hyperparathyroidism, and weight gain,renal insufficiency, GE.  Antipsychotic is also useful for mania & mood stabilization.

 According to a multiple treatments meta- analysis of treatments for acute mania, haloperidol, risperidone, and olanzapine are the most efficacious treatments.

Uses:  MDD.  Bipolar dis.  Schizophrenia.  Additional uses:  TD  Parkinson  NMS  Treatment resistant OCD  Chronic pain  Catatonia.

 Hx, physical exam., CBC, TFT, X-ray & ECG  Additional Ix to r\o any brain lesion. What to use for procedure :  Atropine ( reduces secretions)  General anesthesia.  Succinylcholine ( ms relaxation)  Oxygen.  Place electrode in unilateral NON- DOMINANT part.

 Seizure at least for 25 seconds.  If not induced : hyperventilationS\E  Headache  Post ictal delirium.  Memory loss.

 Absolute :  None  Relative:  Recent CVA  Brain tumor  HTN  Recent MI  Sever osteoporosis\osteoarthitis

 Lithium ---with ECT as it causes delirium  Benzodiazipines---prevents seizure.  No. of sessions:  3-12 for MDD  for bipolar mania.  1-4 for catatonia