Transcript Bipolar Mood Disorder New for 462 (Prof. Al

Bipolar Mood Disorder
Case 3
Management Discussion
Abdullah Al-Subaie F.R.C.P (C)
Professor of Psychiatry
Differential Diagnosis 1
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Idiopathic Basal Ganglia
Calcification
------personality and/or
behavior, to psychosis and
dementia
Cancer
Epilepsy
Fahr disease
AIDS
Medications (eg, antidepressants, baclofen,
bromide, bromocriptine, captopril, cimetidine,
corticosteroids, cyclosporine, disulfiram,
hydralazine, isoniazid, levodopa,
methylphenidate, metrizamide, procarbazine,
procyclidine)
Differential Diagnosis 2
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Circadian rhythm desynchronization
Cyclothymic disorder
Oppositional defiant disorder (in children)
Substance abuse disorders (eg, with alcohol,
amphetamines, cocaine, hallucinogens,
opiates)
Workup 1
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.
Workup 2
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.
Workup 3
• 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.
Workup 4
• 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.
Workup 5
• 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.
Workup 6
• 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.
Workup 7
• 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.
Workup 8
• 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
Workup 9
• 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.
Workup 10
• 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.
Workup 11
• 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.
Outlines of Treatment 1
• 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.
Outlines of Treatment 2
• 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
Indications of Inpatient Treatment
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.
Indications of Inpatient Treatment
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.
Indications of Inpatient Treatment
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.
Indications of Inpatient Treatment
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.
Outpatient Treatment Goals 1
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.
Outpatient Treatment Goals 2
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.
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Pharmacologic Therapy 1
• 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.
• The choice of agent depends on the presence
of symptoms such as psychotic symptoms,
agitation, aggression, and sleep disturbance.
Pharmacologic Therapy 2
• 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.