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

2. 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

3. 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

4. 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

5. 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

6. 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

7. Screening Tools – MDQ and CIDI 3.0
15 Question written survey
Score of 7 + Yes + Moderate/Severe
= Specificity 0.93
CIDI 3.0
12 Question Interview
Score of 9 = 80% risk

8. 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

9. 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!

10. 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

11. 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

12. 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

13. 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!

14. Additional Resources Johns Hopkins Advanced Studies in Medicine
Harvard Pilgrim/UBH Clinical Practice Summary
_0509.PDF
Depression Bipolar Support Alliance
PsychEducation.org
Refer when needed

15. 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

16. Questions and Case Studies
The End!
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Topic:
Questions and
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Studies 16