Transcript Bipolar Disorder - Dr D Green, Psychiatry

Bipolar Disorder in Primary Care:
Tips on How to Diagnose and Treat it
D Green MD
Objectives
• Review epidemiology of bipolar disorder
• Review diagnostic criteria and differential
diagnoses
• Learn when to consider this diagnosis and
an approach to diagnosing it
• Understand the treatment approaches to
bipolar disorder
Case # 1
• 41 year old male treated with Cipralex and
Remeron for severe depression and anxiety
• He gradually improved and was able to
return to work
• Several weeks later his mood changed and
he became more irritable and
argumentative, which was out of character
for him
• His energy increased and became
exercising 3-4 hours per day
Case # 1 (contd.)
• He began to spend money (bought a car
without telling his wife) and to drink more
alcohol
• On a trip to Muskoka he was stopped
several times for speeding
• This continued for a number of weeks
despite the fact that his antidepressants
were quickly weaned off and stopped
Case #2
• 45 year old woman presents with anxiety
and depression treated with Cipralex and
trazodone
• Described episodes lasting 1-2 days when
she would be stay up all night cleaning her
house
• She would then “crash” and sleep for 12-16
hours
• Seen by consulting psychiatrist and
diagnosed with Bipolar II disorder
Case #2
• More history indicated a past history of
trauma and abuse with some symptoms of
PTSD which had been activated by conflict
with a co-worker
• Other stressor was her oldest son, to whom
she was very attached, leaving home
• More detail of episodes indicated presence
of significant anxiety associated with activity
rather than elevated or irritable mood
Case # 3
• 35 year old female with long history of
“mood swings” and tempestuous
relationship with her husband
• Described episodes lasting several days to 1
week of “mania” during which her mood
was “great” and she needed to sleep less
and was up at night engaged in many
activities
• These episodes seemed to be associated
with improvements in psychosocial stressors
Bipolar Disorder Classification
Bipolar I
Bipolar II
Cyclothymic Disorder
Substance/medication induced bipolar
disorder
• Bipolar disorder due to another medical
disorder
• Other specified bipolar disorder
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Bipolar I Disorder
• Diagnosed in patients with one or more
manic episodes
• Nearly always experience at least one
episode of major depression
• however depression is not required for
diagnosis (unipolar mania only present in 5%
of cases)
DSM-5 criteria for manic episode
Bipolar II Disorder
• Diagnosed in patients with a history of at
least one episode of hypomania, at least
one episode of major depression, and no
history of mania
• Estimated that 5 to 15 percent of patients
with bipolar II disorder will eventually suffer
an episode of mania and thus the diagnosis
changes to bipolar I disorder
DSM-5 criteria for a hypomanic episode
Bipolar Disorder Classification
Bipolar I
Bipolar II
Cyclothymic Disorder
Substance/medication induced bipolar
disorder
• Bipolar disorder due to another medical
disorder
• Other specified bipolar disorder
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•
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•
Other specified bipolar disorder
• Short duration (two to three days) and major
depressive episodes
• Hypomanic symptoms for at least 4
consecutive days that do not meet criteria
for a hypomanic episode, and major
depressive episodes
• Hypomanic episodes without prior major
depressive episode
Bipolar spectrum disorder
• Also referred to as “subthreshold bipolar
disorder”
• Variably defined as consisting of milder
forms of one or two of manic or hypomanic
symptoms, lasting for a variable (or
unspecified) period of time
• Lack of evidence to substantiate diagnosis
or its treatment
Mood disorder course specifiers
• Rapid cycling
o Defined as four or more mood episodes
(mania, hypomania, or major depression)
during a 12 month period
• Seasonal pattern
Epidemiology
• Estimated lifetime prevalence of bipolar
disorder among adults worldwide is 1 to 3
percent
• In the US estimated lifetime prevalence of
bipolar I disorder was 1.0 percent and
bipolar II was 1.1 percent
• In primary care settings prevalence
estimated to be from 1 to 4 percent
Comorbidity
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Any anxiety disorder - 75%
ADHD – 50%
Substance abuse – 50%
Eating disorder – 14% (bipolar II disorder)
Suicide risk
• Prevalence of lifetime prevalence of
attempted suicide in bipolar I and II is similar
(32.4% and 36.3%, respectively)
• Lifetime risk of suicide in bipolar disorder is 15
times that of the general population
• May account for one-quarter of all
completed suicides
Genetics of bipolar disorder
• Lifetime risk of bipolar disorder for the first
degree relative of a bipolar proband is 5 to
10 percent.
• Lifetime risk of bipolar disorder for a
monozygotic co-twin is 40 to 70 percent
• Lifetime prevalence in general population is
1 to 3 percent
Note: Genetic factors account for
approximately 80% of cause of the condition
Diagnosis of bipolar
disorder
Diagnosis of bipolar disorder in primary care
• Early, accurate diagnosis can substantially
reduce the burden of bipolar disorder and
can improve the long-term outcome for
patients
• Misdiagnosis of bipolar can lead to
unnecessary treatments
Suspicion of a manic episode
• Usually readily identifiable in most patients,
although the symptomatology may be
variable, especially in elderly
• Frequently require admission to a psychiatric
facility
Suspicion of a hypomanic episode
• More easily missed
• May represent a period of “wellness” after
an episode of depression
• Patients often do not recall all aspects of the
episode and their ability to recall diminishes
over time
Suspicion of bipolar depressive episode
• Symptoms of depression are experienced
most frequently and for the longest duration
in bipolar disorder, and are the most
common reasons for patients to seek care
Clues that might suggest bipolar depression
• Typically earlier (age 13-17) than for MDD(
mid to late 20s)
• Atypical features are more common and
include:
o Hypersomnia, hyperphagia and rejection
sensitivity
o Mood lability, psychotic features,
psychomotor retardation and pathological
guilt
Clues that might suggest bipolar depression
(contd.)
• Bipolar disorder characterized by more
frequent, and more rapid onset, of
recurrences than MDD
• Lack of response to multiple antidepressants
• Family history of mood disorders, especially
bipolar disorder
One approach to
diagnosing bipolar
disorder
1. Seeing someone manic or hypomanic (in
absence of another explanation such as a
medical condition or substance intoxication)
2.Hospital discharge
summary
3. Psychiatric consultation
report*
4. Collateral from family or
friends
Note: Always try to obtain this (with
patient permission)
Collateral from family or friends
• Ask about criteria for mania or hypomania
• Try to establish whether there was a
significant change in functioning or
behaviour recently or in the past
• Ask about substance use
• Ask about family history of bipolar disorder
(more about this later)
5. Patient self-report
Patient self-report
• Need to establish if patient’s symptoms meet
criteria for hypomania or mania
• Not always reliable
• Patients with hypomania or mania often have poor
insight
• Patients may present with major depression and not
recall prior episodes of mania or hypomania,
especially if they were many years ago
• Patients may believe they have the disorder after
reading about it on the internet or being told they
were “bipolar” by their friends
6. Is there is a family history
of bipolar disorder?
Family history of bipolar disorder
• Always ask about this
• If patient unsure remember to ask family
members
• Family member who was “institutionalized” or
received ECT or with suicide attempts or
completions may have had bipolar disorder
• Caveat: not all those family members who are
said to have bipolar disorder have the
condition
Approach to diagnosis of bipolar disorder
1. Assess patient for presence of hypomania
or mania
2. Obtain psychiatric discharge summaries, if
any
3. Review psychiatric consultation report, if
available
4. Obtain collateral from family or friends
5. Assess patient for history of mania or
hypomania
6. Always ask about family history of bipolar
disorder
Screening instruments
Mood Disorders Questionnaire
• In primary care setting sensitivity found to be fair
(58%) and specificity good (93%) in one study
MDQ and borderline personality disorder
• 2010 study by Zimmerman et al. examined
the high false positive rate on MDQ
• Found that positive results on the MDQ were
as likely to indicate that a patient has
borderline personality disorder as bipolar
disorder
Mood Disorders Questionnaire
• Remember it is a screening tool not a case
finding tool
• May miss cases of bipolar II
• False positives are significant and may be
picking up cases of borderline personality
disorder
• Remember to factor in positive response to
family history in your assessment using the
MDQ
Differential Diagnosis
Bipolar disorder and borderline personality
disorder: shared features
• The “mood swings” and irritability of bipolar disorder
can resemble the affective instability and
uncontrolled anger of borderline personality
disorder
• Recurrent suicidal ideation and behaviour
• problematic impulsive behaviour (excessive
spending sprees, sexual promiscuity, substance
abuse, and reckless driving)
• Poor psychosocial functioning
Differential Diagnosis
Bipolar disorder
• Depressive or mood
elevated syndromes longer
in duration (e.g. lasting days
to weeks
• Mood symptoms are less
connected to events in the
environment
• May have periods of
preserved functioning,
when well
Borderline personality disorder
•
Mood swings last minutes to hours
•
Mood symptoms often triggered by
stressors such as perceived rejection or
failure
•
Psychosocial functioning may be
chronically poor
Also marked by unstable and intense
interpersonal relationships, identity
disturbance, chronic feelings of
emptiness, and frantic efforts to avoid
abandonment
•
ADHD and Bipolar disorder
• In both disorders there may be impaired attention
and concentration, distractibility and frequent
changes in activity or plans
• Also common may be difficulty with task
completion, increased activity, restlessness and
talking and disinhibited and inappropriate
behaviour
Differential diagnosis
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Bipolar disorder
Inflated self esteem
and grandiosity
Flight of ideas
Decreased need for
sleep
Excessive involvement
in pleasurable activities
Usually major
depression occurs at
some point
ADHD
• Absent
• Absent
• Absent
• Absent
• Not always present
Substance abuse and bipolar disorder
• Many different substances of abuse (cocaine,
amphetamines, opiates, sedatives) can be
associated with hypomanic or manic-like
symptoms, as well as depressive and psychotic
symptoms
• Complicating the assessment is the substantial comorbidity between bipolar and substance use
disorders
Substance abuse and bipolar disorder
• Extra caution should be taken in compiling a
detailed history of the onset and offset of each
• If substance abuse predates hypomanic or manic
symptom onset then a substance-related mood
diagnosis is more likely
• If self-medication with substances occurs after the
onset of symptoms, then a mood disorder may be
more likely
• A period of abstinence may be required to assist
with clarification of the diagnosis
Organic Causes of Bipolar disorder
• New onset of mania or hypomania especially after
age 40 should increase suspicion of an organic
cause
• Need to consider possibility of a neurologic
condition such as a seizure disorder or CNS tumour
• Also need to medication such as steroids or
Parkinson’s medications
• Consider also SLE, endocrine disorders
Differential Diagnosis (contd.)
• Anxiety disorders (PTSD, GAD)
• Atypical depressive disorders
• Schizoaffective disorder
Management of bipolar disorder in
primary care
 Anyone suspected of having
bipolar disorder should be referred
to psychiatry
Manic Episode
Mania
• Should be sent to hospital for assessment
• May need to certify the patient and call 911
depending upon severity of condition and level of
insight
• If in your office, could give either Ativan 1-2 mg po
or Olanzapine 5-10 mg po depending upon age
and size of patient as well extent of medical
comorbidity
Hypomania
• Quickly taper and stop antidepressants over
the next few days
• Assess for medical condition with physical
exam and screening bloodwork
• If appropriate do urine drug screen
• Assess suicide risk
• Assess safety for driving and report to MOT if
have concerns
Hypomania
• Begin treatment with atypical antipsychotic such
as:
o Olanzapine 5-10 mg po qhs
o Seroquel XR 100 mg (increase in increments of
100 mg every 1-2 days aiming for a dose of 400600 mg q supper, as tolerated)
o Risperidone 2-3 mg po qhs, may need to
increase further in increments of 1-2 mg to a
maximum dose of 6 mg
CANMAT algorithm for mania
Hypomania
• Patient requires close follow up and
education of family members and friends
regarding diagnosis and crisis resources
• Requires urgent referral to psychiatrist
Bipolar depression
• Rule out organic cause with physical exam
and screening bloodwork including CBC,
lytes, BUN, creatinine, TSH, B12 and folate
• Consider urine drug screen and assess for
alcohol abuse
• Assess suicide risk
• Refer to psychiatry for diagnostic
confirmation and management
recommendations
CANMAT algorithm for bipolar depression
Treatment of bipolar depression
Treatment of bipolar depression
• Avoid antidepressants if possible
• If using antidepressants never use alone, should
always be used with a mood stabilizer (lithium,
valproic acid) or atypical antipsychotic
• Safest strategy may be to start with;
o Seroquel XR , day 1 - 50 mg at supper, day 2- 100
mg, day 3- 200 mg and day 4 – 300 mg onwards
or
o Lamotrigine, 25 mg po daily X 2 weeks, then 50
mg po daily X 2 weeks, then 100 mg po daily X 1
week, then double dose to 200 mg po daily and
maintain (watch for rash and stop if occurs)
Ongoing monitoring
• Once stable important to use chronic disease
management principles including psychoeducation and other self-management strategies
(Mood Disorders Ottawa) and regular follow up and
monitoring
• If on antipsychotics need at least annual
assessment of weight, abdominal circumference,
BP, fasting lipids and glucose
• If on lithium need to check Li level, Bun and
creatinine and serum Ca every 6-12 months
Case # 1
• 41 year old male treated with Cipralex and
Remeron for severe depression and anxiety
• He gradually improved and was able to
return to work
• Several weeks later his mood changed and
he became more irritable and
argumentative, which was out of character
for him
• His energy increased and became
exercising 3-4 hours per day
Case # 1 (contd.)
• He began to spend money (bought a car
without telling his wife) and to drink more
alcohol
• On a trip to Muskoka he was stopped several
times for speeding
• His wife contacted the family health team and
he reluctantly agreed to come for an
assessment
• He was found to be irritable and admitted to
having more energy than usual with little need
for sleep
Approach to diagnosis of bipolar disorder
1. Assess patient for presence of hypomania
or mania
2. Obtain psychiatric discharge summaries, if
any
3. Review psychiatric consultation report, if
available
4. Obtain collateral from family or friends
5. Assess patient for history of mania or
hypomania
6. Always ask about family history of bipolar
disorder
Case # 1
• Organic w/u and drug screen were negative
• Wife confirms abrupt change in his behaviour
• Family history positive with 2 cousins with bipolar
disorder possibly on Lithium
• He was diagnosed with bipolar II
• His antidepressant were quickly tapered and
stopped
• Olanzapine 5 mg po qhs was started
• MOT later contacted
Case #2
• 45 year old woman presents with anxiety
and depression treated with Cipralex and
trazodone
• Described episodes lasting 1-2 days when
she would be stay up all night cleaning her
house
• She would then “crash” and sleep for 12-16
hours
• Seen by consulting psychiatrist and
diagnosed with Bipolar II disorder and
lurasidone recommended
Case #2
• More history indicated a past history of trauma and
abuse with some symptoms of PTSD which had been
activated by conflict with a co-worker
• Other stressor was her oldest son, to whom she was very
attached, leaving home
• More detail of episodes indicated presence of significant
anxiety associated with activity rather than elevated or
irritable mood
• When seen no evidence of pressured speech or
irritability or euphoria was present
• Stated her brother had been diagnosed with “bipolar
disorder” but had never seen a psychiatrist and had also
a history of significant substance abuse
Approach to diagnosis of bipolar disorder
1. Assess patient for presence of hypomania
or mania
2. Obtain psychiatric discharge summaries, if
any
3. Review psychiatric consultation report, if
available
4. Obtain collateral from family or friends
5. Assess patient for history of mania or
hypomania
6. Always ask about family history of bipolar
disorder
Case # 2
Husband contacted
Described her as always being a worrier
Never seen her like this
Notes she was quite preoccupied with
trauma from her childhood
• Confirmed pattern of poor sleep X 1 night
followed by her “crashing”
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Case # 2
• Diagnosed with GAD, PTSD and MDD
• Recommended that she not start on
Lurasidone
• Recommended ongoing f/u with FHT SW for
ongoing psychotherapy, as she found it
helpful
• At f/u 1 month later much improved
Case # 3
• 35 year old female with long history of “mood
swings” and tempestuous relationship with her
husband
• Described episodes lasting several days to 1 week
of “mania” during which her mood was “great” and
she needed to sleep less and was up at night
engaged in many activities
• These episodes seemed to be associated with
improvements in psychosocial stressors
Case # 3
• No psychiatric admissions
• Psychiatric consultations in past suggested
diagnoses of depression, anxiety and
borderline PD
• No collateral could be obtained
• Not evidently manic or hypomanic when
seen, despite claiming to be
Case # 3
• Diagnosed with MDD, anxiety and
borderline PD
• Given some uncertainty about diagnosis
started on Seroquel XR as also has indication
for MDD as well as bipolar, both depressed
and manic phase
• Did not tolerate this and so placed on
Cymbalta for anxiety and depression which
was helpful and did not seem to lead to
hypomania or mania
In summary
• Bipolar disorder should be considered in every
patient presenting with depressive symptoms
• It is a relatively rare condition however
• Attention to presence of active mania or
hypomania, collateral, and family history can help
clarify the diagnosis
• Confirmation or uncertainty about presence of
bipolar disorder should prompt a psychiatric referral
• Remember CANMAT guidelines can be useful aid in
managing this condition