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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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bipolar disorder diagnosis management and treatment

Bipolar Disorder – Diagnosis, Management and Treatment

November 6, 2001

Swedish Family Practice Residency

outline
Outline
  • Prevalence of psychiatric disorders
  • Prevalence and diagnosis of bipolar disorders
  • Patient Information Handout - reading
  • Physician Information Handout – reading
  • Break
  • Case discussion – 4:00 sharp
  • More cases (if time)
  • Who Wants to be a Psychiatrist? (if time)
overview of the impact of mental illness in primary care
Overview of the Impact of Mental Illness in Primary Care
  • Prevalence of psychiatric disorders
  • Prevalence of bipolar disorders
  • One year prevalence vs. lifetime prevalence
  • General population vs. clinic waiting room
  • Multiple diagnoses/co-morbid conditions
common psychiatric disorders
Mood Disorders 12.5%

Depression 5%

Major depressive disorder Minor depressive disorder PMDD

Dysthymia 5.4%

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%)

PTSD 2.6%

GAD 2% (5%)

OCD 2.1%

Panic Disorder 1.3%

Anxiety due to illness, medications, drugs, etc.

In your office 25-35%

Common Psychiatric Disorders
psychiatric disorders in children
All Mental Disorders

12-15%

ADHD 2.2-9.9%

Conduct Disorder 1.5-5.5%

Separation Anxiety 2.3-9.2%

Specific Phobias 2.3-9.2%

Major Depressive Disorder 1% in young children to 8.3% in adolescents

Bulemia 1.1-4.2% of adolescents

Anorexia .5-3.7% of adolescents

Psychiatric Disorders in Children
other psychiatric disorders
Unexplained physical sympoms (25% of visits)

Hypochondriasis 4-9%

Somatization disorder (.2-2%)

Conversion disorder

Pain disorder

Malingering

Factitious disorder

Schizophrenia 1%

Cognitive Disturbance

Delirium

Dementia 2.7% (20% over 85)

Substance Abuse

Alcohol (13%)

Other drugs (1%)

Sleep disturbance 30-40%

Other Psychiatric Disorders
bipolar disorder
Bipolar Disorder I

Lifetime 1.6%

Mean age of onset early 20’s

Clusters in families

15% suicide

Bipolar Disorder II

Lifetime 0.5%

Cyclothymia

Lifetime .4-1%

Bipolar Disorder
bipolar i disorder
Manic episode* lasts over one week or requires hospitalization

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 investments

Bipolar I Disorder
bipolar i disorder10
May have psychotic symptoms when manic or depressed

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 episodes

Bipolar I Disorder
mixed episode
Symptoms of both mania and major depression*

Symptoms may alternate during the day

Often more disabling and difficult to treat

*Excitable or agitated but irritable and depressed instead of feeling euphoric

Mixed Episode
rapid cycling
At least four episodes a year of manic, hypomanic, mixed or depressive episodes

Present in 5% to 15% of patients with bipolar disorder

May be triggered by taking antidepressants for depressive episodes

Rapid Cycling
bipolar ii disorder
Hypomanic episode* lasting 4 days or longer not requiring hospitalization

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 episodes

Bipolar II Disorder
cyclothymia
Chronic mood disturbance with many periods of hypomania and depressed mood

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 disorder

Cyclothymia
case 1
Case #1

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.

slide16
Read Patient Information
  • Read Physician Information
  • Take a Break
  • Be back by 4:00 to discuss cases and play “Who Wants to be a Psychiatrist?”
case 2
Case #2

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?

case 218
Case #2

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.

case 219
Case #2

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.

case 220
Case #2

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.

case 221
Case #2

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.

case 3
Case #3

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.

case 323
Case #3

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.

case 324
Case #3

What possible diagnoses would you consider?

What medications would you consider?

case 325
Case #3

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.

case 326
Case #3

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?

case 327
Case #3

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.

live from sfm
Live From SFM

with

Swedish FP Residents

who wants to be a psychiatrist

Who Wants to be a Psychiatrist?

Forget the millionaires

rank in age from oldest to newest
Rank in age from oldest to newest

Prozac

Zoloft

Paxil

Celexa

fastest hand 3 put the following tv medical dramas in order from oldest to newest
Fastest Hand #3Put the following TV medical dramas in order from oldest to newest

Doogie Howser, MD

Dr. Kildare

E.R.

St. Elsewhere

put the following tv medical dramas in order from oldest to newest
Put the following TV medical dramas in order from oldest to newest

Dr. Kildare

St. Elsewhere

Doogie Houser, MD

E.R.

slide55
Which of the following antidepressants is most likely to trigger a manic switch in a patient with bipolar depression?
slide56
Which of the following antidepressants is most likely to trigger a manic switch in a patient with bipolar depression?
the end

The End

Thank You