Transcript What is the course of Bipolar I Disorder?

The Depressed Patient
A Patient-Centered, Evidence-Based Diagnostic
and Treatment Process1,2
A Presentation for
SOMC Medical Education
Kendall L. Stewart, MD, MBA, DFAPA
December 17, 2010
1My
aim is to offer practical insights you can put to use in your professional life.
let me know whether I have succeeded on your evaluation forms.
2Please
Why is this important?
• This is a common, serious
disorder.1,2
• The lifetime prevalence is
between 15 and 20-percent.
• About 10-percent of patients
who present to primary care
physicians are depressed.
• About 15-percent of medical
inpatients are depressed.
• Women are depressed about
twice as often as men.
• It is as disabling as coronary
artery disease or arthritis.
• It is among the most
common reasons for seeing a
physician.
1This
• After listening to this
presentation, you will
be able to answer the
following questions:
disorder is frequently missed and often inadequately treated.
is the most effective screening tool?
2What
– Why is this important?
– How do these patients
present?
– What are the
diagnostic criteria?
– What is the
differential diagnosis?
– What is the treatment?
– What are some of the
treatment challenges?1
How do these patients present?
• “I’m just down all the time.”
• “I just can’t seem to get myself
going.”
• “Life doesn’t seem to mean
much anymore.”
• “I don’t get along with my
husband like I used to.”
• “I can’t sleep.”1
• “I have a lot of headaches.”
• “I have this hurting in my
chest now and then.”
• “I’ve been depressed on and off
throughout my life.”2
• “It usually didn’t last very
long, but now I’m depressed
for weeks at a time.”
1Treating
2Major
• “I’ve seriously considered
suicide, but I wouldn’t want to
do that to my children.”
• “I can’t seem to fall to sleep,
but then I wake up early and
can’t get back to sleep.”
• “I feel helpless, hopeless and
worthless.”
• “I can’t concentrate.”
• “I don’t enjoy anything
anymore.”
• “I’m tired all the time.”
• “I don’t enjoy sex at all.”
• “I have a pretty good life; I
can’t figure out why I would
feel this way.”
• You can listen to a depressed
man talk about his struggle
here.
your older patients’ unrealistic expectations that they will sleep through the night will challenge you.
depressive episodes are often superimposed on Dysthymic Disorder.
What are the diagnostic criteria for
Major Depression?
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A change from a previous level of functioning
One of the following
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Five or more of the following symptoms during a
continuous two-week period
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–
–
–
–
–
–
–
•
•
•
•
1Here
Depressed mood
Inability to experience pleasure
Depressed mood
Markedly diminished interest
Significant weight loss or gain without explanation
Insomnia or hypersomnia
Psychomotor agitation or retardation
Feelings of worthlessness or guilt
Inability to concentrate
Recurrent thoughts of death
No evidence of a mixed episode
Significant distress or impairment
Not due to drugs
Not caused by bereavement1
are the keys to your success as a physician: Listen attentively. Accept the patient’s feelings.
Ask clarifying questions. Ask if they believe you understand. Ask permission to tell them your opinion.
Go over all the options. State the ultimate goal. Recommend the best option. Admit how much you don’t know.
What are the different diagnoses of
depression?
• Mood Disorders
– Depressive Disorders
• Major Depressive Disorder1
• Dysthymic Disorder
• Depressive Disorder Not Otherwise
Specified (NOS)
– Bipolar Disorders2,3
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•
•
•
Bipolar I Disorder
Bipolar II Disorder
Cyclothymic Disorder
Bipolar Disorder NOS
– Mood Disorder due to General Medical
Condition (GMC)
– Substance-Induced Mood Disorder
– Mood Disorder NOS
1With
the older antidepressant medications, I used to know how to diagnose major depression.
disorders are easily missed—and mistreated.
3Ask the patient and her family key screening questions.
2These
What is the course of Major
Depression?
10
8
6
4
2
Normal 0
Life
Week 1
Week 2
Week 3
Week 4
Week 5
Week 6
Week 7
Week 8
-2
-4
-6
-8
-10
Symptom Intensity Scale
Week 9
Week 10 Week 11 Week 12
What is the course of Dysthymic
Disorder?
10
8
6
4
2
Normal 0
Life
Week 1
Week 2
Week 3
Week 4
Week 5
Week 6
Week 7
Week 8
-2
-4
-6
-8
-10
Symptom Intensity Scale
Week 9
Week 10 Week 11 Week 12
What is the course of Bipolar I
Disorder?
10
8
6
4
2
Normal 0
Life
Week 1
Week 2
Week 3
Week 4
Week 5
Week 6
Week 7
Week 8
-2
-4
-6
-8
-10
Symptom Intensity Scale
Week 9
Week 10 Week 11 Week 12
What is the course of Bipolar II
Disorder?
10
8
6
4
2
Normal 0
Life
Week 1
Week 2
Week 3
Week 4
Week 5
Week 6
Week 7
Week 8
-2
-4
-6
-8
-10
Symptom Intensity Scale
Week 9
Week 10 Week 11 Week 12
What is the course of Cyclothymic
Disorder?
10
8
6
4
2
Normal 0
Life
Week 1
Week 2
Week 3
Week 4
Week 5
Week 6
Week 7
Week 8
-2
-4
-6
-8
-10
Symptom Intensity Scale
Week 9
Week 10 Week 11 Week 12
What is the differential diagnosis?
• Normal depression
– Grief
• Other depressive disorders
– Bipolar disorders
• Depression secondary to a general
medical condition
– Cancer
• Substance-induced depression
– Recent use of steroids1
• Depression secondary to other
psychiatric disorders
– Panic Disorder
1I
have often seen steroids cause both depression and mania.
What is the treatment?
• Depression
– Provide reassurance.
– Consider paroxetine 20 mg/day
and increase to maximum dose
of 60 mg/day.
– Follow an evidence-based
algorithm for treatment
resistant depression.1,2
– Consider referral to a
psychiatrist.
• Suicidal risk
– Conduct a careful risk
assessment.
– Document your assessment.
– Take appropriate precautions.
• Insomnia
– Consider the short-term use of
your favorite sleeper.
1We
• Other comorbid disorders
– Diagnose and treat these
conditions vigorously.
• Maladaptive attitudes and
behaviors
– Consider cognitive behavioral
psychotherapy (CBT)
• Education and self help
– Provide educational resources.
– Recommend a daily exercise
regimen.
– Recommend a healthy diet.
– Suggest healthy distractions.
– Recommend meditation.
– Recommend online resources
with caution.
– Recommend self help groups
with caution.
all go through life trying to do as much of what we want to do and as little of what we don’t want to
do as possible. The key is to learn to want to do more of the right things.
2The values-based life is the most satisfying.
What are some of the treatment
challenges?
• Only 30 to 40-percent of patients achieve a
complete remission with the first adequate trial
of antidepressant medication.
• The treatment of the rest of these folk is tough
and complicated.
– Failure to comply is often an issue.
– Accompanying personality disorders are very
tough to treat.1
– Partial remission is often the best result you can
realistically achieve.
– Depression usually recurs, and is best managed
as a chronic illness.
– Chronically-suicidal patients are particularly
challenging.
1I
once treated a beautiful young woman who was a rock band groupie.
Where can you learn more?
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American Psychiatric Association, Diagnostic and Statistical Manual
of Mental Disorders, Fourth Edition, Text Revision, 2000
Sadock, B. J. and Sadock V. A., Concise Textbook of Clinical
Psychiatry, Third Edition, 20081
Flaherty, AH, and Rost, NS, The Massachusetts Handbook of
Neurology, April 20072
Stead, L, Stead, SM and Kaufman, M, First Aid© for the Psychiatry
Clerkship, Second Edition, March 2005
Klamen, D, and Pan, P, Psychiatry Pre Test Self-Assessment and
Review, Twelfth Edition, March 20093
Oransky, I, and Blitzstein, S, Lange Q&A: Psychiatry, March 2007
Ratey, JJ, Spark: The Revolutionary New Science of Exercise and the
Brain, January 2008
Medina, John, Brain Rules: 12 Principles for Surviving and Thriving
at Home, Work and School, February 2008
Stewart KL, “Dealing With Anxiety: A Practical Approach to Nervous
Patients,” 2000
Where can you find evidence-based
information about mental disorders?
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Explore the site maintained by the organization where evidence-based
medicine began at McMaster University here.
Sign up for the Medscape Best Evidence Newsletters in the specialties
of your choice here.
Subscribe to Evidence-Based Mental Health and search a database at
the National Registry of Evidence-Based Programs and Practices
maintained by the Substance Abuse and Mental Health Services
Administration here.
Explore a limited but useful database of mental health practices that have
been "blessed" as evidence-based by various academic, administrative and
advocacy groups collected by the Iowa Consortium for Mental Health here.
Download this presentation and related presentations and white papers at
www.KendallLStewartMD.com.
Learn more about Southern Ohio Medical Center and the job opportunities
there at www.SOMC.org.
Review the exceptional medical education training opportunities at Southern
Ohio Medical Center here.
How can you contact me?1
Kendall L. Stewart, M.D.
VPMA and Chief Medical Officer
Southern Ohio Medical Center
Chairman & CEO
The SOMC Medical Care Foundation, Inc.
1805 27th Street
Waller Building
Suite B01
Portsmouth, Ohio 45662
740.356.8153
[email protected]
[email protected]
www.somc.org
www.KendallLStewartMD.com
1Speaking
and consultation fees benefit the SOMC Endowment Fund.
Are there other questions?
Sarah Porter, DO
SOMC FP 2007
www.somc.org
Ryan Foor, DO
OUCOM 2005
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