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Bipolar Disorder – Diagnosis, Management and Treatment. November 6, 2001 Swedish Family Practice Residency. Outline . Prevalence of psychiatric disorders Prevalence and diagnosis of bipolar disorders Patient Information Handout - reading Physician Information Handout – reading Break
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November 6, 2001
Swedish Family Practice Residency
Major depressive disorder Minor depressive disorder PMDD
Bipolar Disorders 2.1-2.7%
Depression due to illness, medications, drugs, bereavement, adjustment
In your office 20-30%
Anxiety Disorders 12.6%
Specific Phobias 3.2% (10-11.3%)
Social Phobia 2.7% (3-13%)
GAD 2% (5%)
Panic Disorder 1.3%
Anxiety due to illness, medications, drugs, etc.
In your office 25-35%Common Psychiatric Disorders
Somatization disorder (.2-2%)
Dementia 2.7% (20% over 85)
Other drugs (1%)
Sleep disturbance 30-40%Other Psychiatric Disorders
40% to 80%!
Are you missing something?
Not secondary to substance abuse
Causes impairment of normal functioning
*Mania – grandiosity, increased self-esteem, decreased need for sleep, flight of ideas, agitation, excessive involvement in pleasurable activity -buying spree, sex, business investmentsBipolar I Disorder
No psychotic symptoms when stable
(distinguishes from schizophrenia or schizoaffective disorder)
Major depressive episodes often precede or follow manic episodes
80% will have multiple episodes
Kindling effect of multiple episodesBipolar I Disorder
Present in 5% to 15% of patients with bipolar disorder
May be triggered by taking antidepressants for depressive episodesRapid Cycling
Not secondary to substance abuse
No impairment of normal functioning
*Hypomania - elevated, expansive or irritable mood but not as severe as mania
Major depressive episodes often precede or follow hypomanic episodesBipolar II Disorder
Episodes are generally shorter than in bipolar I or II
No episodes meet criteria for mania or major depressive disorder
15% to 50% risk of developing bipolar I or II disorderCyclothymia
A twenty-six year old woman presents to your Saturday clinic. She just moved to Seattle from the Midwest and is living in her car. She is somewhat unkempt, tense, hyper-vigilant and paranoid. She has not eaten in several days and has only slept for a few hours a night over the past several weeks.
Forty-nine year old male who has been kicked out of his mother’s clinic because of bizarre behavior. He is taking lithium, depakote and carbamazepine. He is alert and oriented but indeed is behaving rather strangely in your clinic, threatening the front desk staff with push-pins and crawling on the floor. What would you like to know about his past medical history?
The patients tells you he has been in the hospital at least twice a year for the past 20 years and with a weird twinkle in his eye, he challenges you to see if you can keep him out of the hospital.
You increase the doses of all three mood stabilizers to therapeutic blood levels but despite complete compliance with all his medications, the patient is found squirting everyone in his neighborhood with his hose and doing the same in the neighborhood around your clinic. The police bring him to you to take care of.
After being hospitalized and sedated for several days, the patient is discharged back to your care on clonazepam, haldol and valproate. He is relatively stable for a few weeks and then becomes very depressed and stops his haldol and valproate.
What medications might you try now?
The patient does well on your new regime for several months but them becomes very depressed.
What medication might you try now?
The patient does well on his new medication regime for 6 years with no psychiatric hospitalizations.
A thirty-three year old woman presents to your office with a history of sexual abuse as a teenager and forced hospitalization with over 12 ECT treatments after telling her mother that her father was the abuser. She has only vague memories of either having had an abortion or delivering a child during her several months of hospitalization.
The patient has tried to get her sisters to admit to similar abuse during their childhood but her whole family, including her parents think she is crazy and treat her like an outcast. The patient has been in and out of the hospital for twenty years with episodes of paranoia and delusions. Between hospitalizations she is free of delusional thinking and has managed to graduate from high school and has finished several years of college.
What possible diagnoses would you consider?
What medications would you consider?
You manage the patient with various mood-stabilizers but she is reluctant to take them for long because of side-effects. Despite your best work in trying to convince her that she will need to take medications for the rest of her life, she is reluctant to take anything for very long and ends up in the hospital every four to six months.
After her fourth hospitalization she finally accepts the fact that she would do better if she would take her medications and does so until she gets acutely toxic on lithium after being given a shot of toradol in the ER and getting rashes from both valproate and carbamazepine. What medications would you try now?
On your new medication regime your patient remains stable for 8 years with no hospitalizations. As long as she doesn’t work more than 20 hours a week and has minimal contact with her family she does fine. When her mother visits or she visits her mother you see her in clinic once or twice a week as needed.
Swedish FP Residents
Forget the millionaires
Doogie Howser, MD
Doogie Houser, MD