Treating Bipolar Disorder
in the Primary Care Setting
Presented by: Jonathan Betlinski, MD
Date: 10/16/2014
Disclosures and Learning Objectives
• Learning Objectives
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Be able to name three treatments for
mania/hypomania
Be able to name three treatments for
bipolar depression
Be able to name three lifestyle
treatments for bipolar disorder
Disclosures: Dr. Jonathan Betlinski has nothing to disclose.
Treating Bipolar Disorder in Primary Care
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Review screening for Bipolar Disorder
Review treatments for mania/hypomania
Review treatments for bipolar depression
Review strategies for maintenance
• Next Week's Topic
Manic Episode
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Distractibility
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Involvement in pleasurable activities that have a high
potential for painful consequences
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Grandiosity or inflated self-esteem
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Flight of ideas or subjective experience that thoughts
are racing
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Activity increase or psychomotor agitation
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Sleep need decreased
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Talkative or pressure to keep talking
http://www.ncbi.nlm.nih.gov/books/NBK64063/
Mania vs. Hypomania
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Mania
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Lasts 7 days
OR requires hospitalization
OR includes psychosis
AND causes significant impairment
Hypomania
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Only has to last 4 days
Does not cause significant impairment
http://www.ncbi.nlm.nih.gov/books/NBK64063/
The Bipolar Disorders
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Bipolar I Disorder
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Bipolar II Disorder
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Recurrent Major Depressive Episodes
with Hypomanic episodes
Cyclothymia
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Manic Episode(s) +- depression
Chronic cycling between hypomania and
dysthymia
Bipolar Disorder NOS
http://www.ncbi.nlm.nih.gov/books/NBK64063/
Screening Tools – MDQ and CIDI 3.0
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MDQ
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15 Question written survey
Score of 7 + Yes + Moderate/Severe
= Specificity 0.93
http://www.integration.samhsa.gov/images/res/MDQ.pdf
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CIDI 3.0
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12 Question Interview
Score of 9 = 80% risk
http://www.integration.samhsa.gov/images/res/STABLE_toolkit.pdf
Treating Mania/Hypomania
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Stop antidepressants (or inciting agents)
Use a mood stabilizer first
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If psychosis occurs, use an antipsychotic
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Lithium, Valproate
Carbemazepine, Oxcarbazepine
Olanzapine, Risperidone, Asenapine?
Aripiprazole, Ziprasidone, Quetiapine
Consider short term use of a benzo
http://www.jhasim.com/files/articlefiles/pdf/ASM_6_6A_p442_458_R1.pdf
http://psychiatryonline.org/content.aspx?bookid=28&sectionid=1682557
Treating Depression in Bipolar Disorder
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Start with lithium or lamotrigine
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“Antidepressant monotherapy is not
recommended.”
Add lamotrigine or bupropion if needed
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Quetiapine, olanzapine/fluoxetine
Paroxetine, Venlafaxine. Pramipexole?
ECT if severely depressed or pregnant
CBT and Behavioral Activation, too!
http://psychiatryonline.org/content.aspx?bookid=28&sectionid=1682557
http://www.jhasim.com/files/articlefiles/pdf/ASM_6_6A_p442_458_R1.pdf
Rapid Cycling Bipolar Disorder
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4 or more mood episodes per year
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Identify and treat comorbid contributors
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At least partial remission for 2 months
OR switch to episode of opposite polarity
Hypothyroidism or drug/alcohol use
Taper contributing medications
Lithium, Valproate or Lamotrigine
Combination treatment often required
http://psychiatryonline.org/content.aspx?bookid=28&sectionid=1669577
http://www.jhasim.com/files/articlefiles/pdf/ASM_6_6A_p442_458_R1.pdf
Maintenance for Bipolar Disorder
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Continue agent that helped in acute phase
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Taper benzodiazepines
Taper antipsychotics when mood stable
Lamotrigine may help ward off depression
Lithium may be better at warding off mania
Valproate, Olanzapine, Carbemazepine,
Oxcarbazapine also evidence-based
http://psychiatryonline.org/content.aspx?bookid=28&sectionid=1669577
http://psychiatryonline.org/content.aspx?bookid=28&sectionid=1682557
http://www.jhasim.com/files/articlefiles/pdf/ASM_6_6A_p442_458_R1.pdf
Non-Pharmacologic Maintenance
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Family Focused Therapy
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Cognitive Therapy
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Fewer/shorter episodes and admissions
Psychosocial interventions
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Fewer relapses and longer intervals
Extends remission, decreases recurrence
Light/sleep management
Omega-3 Fatty Acids
http://www.psycheducation.org/depression/meds/Omega-3.htm
http://psychiatryonline.org/content.aspx?bookid=28&sectionid=1682557
Lifestyle Changes for Bipolar Disorder
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Eliminate alcohol, caffeine, and nicotine
Eliminate illicit substances (+cannabis)
Regular exercise
Balanced diet (Omega-3 Fatty Acids)
Mood charts
Avoid Blue Light (especially night lights)
Sleep Hygiene!
http://www.psycheducation.org/depression/LightDark.htm
http://www.jhasim.com/files/articlefiles/pdf/ASM_6_6A_p442_458_R1.pdf
Additional Resources
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Johns Hopkins Advanced Studies in Medicine
http://www.jhasim.com/files/articlefiles/pdf/ASM_6_6A_p442_458_R1.pdf
http://www.jhasim.com/files/articlefiles/pdf/asm_6_6a_p430_441.pdf
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Harvard Pilgrim/UBH Clinical Practice Summary
https://www.harvardpilgrim.org/pls/portal/docs/PAGE/PROVIDERS/MEDMGMT/GUIDELINES/BIPOLAR_CPG_PCP
_0509.PDF
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Depression Bipolar Support Alliance
http://www.dbsalliance.org
http://www.dbsaoregon.org/
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PsychEducation.org
http://www.psycheducation.org/
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Refer when needed
http://ps.psychiatryonline.org/article.aspx?articleid=1861987
http://www.healthline.com/health-blogs/bipolar-bites/family-doctors-cannot-be-expected-treat-bipolar-disorder
Summary
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PCPs can provide life-changing
psychiatric and medical treatment for
bipolar disorder!
Recognizing Bipolar Disorder is much
easier using the MDQ and/or CIDI 3.0
Pharmacology inevitably includes a
mood stabilizer
Lifestyle management is important
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2902189/
The End!
Next Week's
Topic:
Questions
and
Case
Studies
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