1. Waiting for the Psychiatry Consult Treatment of Suspected Bipolar Disorder in the FM Office Spring 2008 Karen S. Blackman, M.D., Department of Family Medicine, Michigan State University Karen Kent VanGorder M.D., Sparrow Health System Family Medicine Residency karen.blackman@hc.msu.edu kentka@msu.edu

2. ksb/kkv Spring 2008 Teaching Goals Accept your responsibility to teach the scientific discipline of psychiatry Teach residents a systematic approach to the initial medication management of bipolar disorder Model and offer didactics to accomplish this

3. ksb/kkv Spring 2008 Today’s Objectives Process: An approach to making a decision on which medication to use in suspected Bipolar Disorder (PHASE) Content: Medications for Bipolar Disorder (charts) Practice: Exercise on choosing a medication for suspected bipolar patients

4. ksb/kkv Spring 2008 Why Teach Psychiatric Interventions in Family Medicine? Much of the total psychiatric care in this country is administered by non-psychiatrist physicians The number of patients treated in primary care vs. specialty mental health care settings for minor psychiatric disorders is equal in some studies Psychiatry is the medical science of treating mental illness Family physicians are often the only scientific/medical part of the mental health team

5. ksb/kkv Spring 2008 Why Teach How to Treat Suspected Bipolar Disorder? Waiting for initial treatment with a psychiatrist may mean patient in any phase of Bipolar Disorder worsens. Treating bipolar patients with the usual treatment for depression (antidepressants!) can make them worse What if I’m wrong?

6. ksb/kkv Spring 2008 How DOES Bipolar Disorder Present to the Family Medicine Office? You are seeing this now The patient who carries a previous diagnosis of Bipolar Disorder  and is on a program that is causing side effects The patient who is referred by a behavioral scientist  for possible hypomania or mania The patient who is depressed  But there’s just something different and worrisome about their story…

7. ksb/kkv Spring 2008 Approach to Choosing Medication in Suspected Bipolar Disorder PHASE PHase of Bipolar Disorder suspected Acuity Side effects Ease of use

8. ksb/kkv Spring 2008 What are the Phases of Bipolar Disorder? Depression Hypomania/Mania Euthymic, or Maintenance

9. ksb/kkv Spring 2008 After Phase, Determine Acuity How ill is this patient? How urgent is it that the patient respond right away?  Medication strategies have varying times of onset of action

10. ksb/kkv Spring 2008 Depression Urgently depressed  Atypical antipsychotics may be fastest  Lamotrigine may be slowest  Maximizing mood stabilizer already present is first line strategy  Antidepressant role is after mood stabilizer only Nonurgently depressed  Not profoundly depressed, but history suspicious for bipolar  Consider lamotrigine

11. ksb/kkv Spring 2008 Mania/Hypomania Urgently manic  Remember: always maximize a mood stabilizer if already present  Atypical antipsychotics are fastest Less urgent: hypomania  Not full blown mania, but manic-like  Consider starting mood stabilizer as this will be definitive treatment (e.g., lithium, lamictal)  Could use antipsychotic low dose for current symptoms

12. ksb/kkv Spring 2008 Maintenance Nonurgent: Maintenance Phase  Patient with history of bipolar  May be on a mood stabilizer they do not like  May be on inappropriate medication for bipolar (SSRI alone)  May be on no medication  Consider: nonantipsychotic mood stabilizer like lamotrigine or lithium

13. ksb/kkv Spring 2008 Now, Consider Side Effects Antipsychotics  Metabolic syndrome  Neurologic risks: extra-pyramidal symptoms and tardive dyskinesia  Neuroleptic malignant syndrome Lamotrigine  1/1000 risk of life threatening rash  Insomnia, fatigue, mental clouding at high doses

14. ksb/kkv Spring 2008 Side Effects, Continued Lithium  GI effects  Toxicity risk Carbamazepine/oxcarbazepine  Agranulocytosis reported with carbamazepine  Drowsy, GI side effects Valproate  Weight gain, hair loss  PCOS

15. ksb/kkv Spring 2008 Lastly, Consider Ease of Use Antipsychotics  Monitor blood glucose, lipids, weight, abdominal circumference, neurologic side effects  No levels Lamotrigine  Monitor for rash at each visit  No levels required  Estrogen containing OCs lower by 50%

16. ksb/kkv Spring 2008 Ease of Use Lithium  Levels  Thyroid exam  Labs: TSH, Renal function  NSAIDs raise, caffeine lowers Carbamazepine/oxcarbazepine  Levels with carbamazepine Not with oxcarbazepine  WBCs. LFTs, thyroid and renal function

17. ksb/kkv Spring 2008 Ease of Use Valproate  LFT  Levels  CBC  Weight

18. ksb/kkv Spring 2008 Practice Choosing a medication for a suspected bipolar patient Divide in pairs: work through options together, discuss, then choose. Consider: PhASE Discussion