Transcript Bipolar Mood Disorder New for 462 (dr. noor)

Abdullah Al-Subaie F.R.C.P (C)
Professor of Psychiatry
•
•
•
•
•
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)




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
–
4.
Leaving such a person alone would be dangerous
and not therapeutic.
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.
4.
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.
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.
http://www.facebook.com/awthq.sa
@awthq



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 metaanalysis 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 NONDOMINANT part.


Seizure at least for 25 seconds.
If not induced : hyperventilation
S\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
10-20 for bipolar mania.
1-4 for catatonia