Hey, you! Are you Bipolar, Depressed, Borderline, or What?

1. Hey, you! Are you Bipolar, Depressed, Borderline, or What? John L. Schaeffer, D.O. Child, Adolescent & Adult Psychiatrist Kaiser Permanente Psychiatry Roseville, CA October 17, 2009

2. Disclosure of Relevant Financial Relationships Dr. Schaeffer has disclosed that he has no relevant relationships with commercial or industry organizations. The CME Department has reviewed disclosure information for the planners and developers for this program and they do not have relationships that present a relevant conflict of interest.

3. The assigned task: • At the end of this conference, participants should be able to: • Demonstrate interviewing techniques for differentiating bi-polar vs depression and other psychiatric diagnoses. • List psych meds and interactions with meds commonly seen in Primary Care.

4. Aren’t these pretty leaves?

5. “Kids: They dance before they learn there is anything that isn’t music.”William Stafford

6. Primary Care at Kaiser You are the Spinal Cord of this organization. The psychiatry department exists to support you. And 70 percent of what walks through your door is psychiatric. So, “Why,” you ask “does psychiatry always dump patients back on us?”

7. Because there are only 20 psychiatrists (only four of which are subspecialty trained and actively working as child/adolescent psychiatrists) to support over 200 primary care doctors in the North Valley.

8. Primary Care at Kaiser Permission to use cartoon per Dwayne Booth

9. Though I’m sure it must sometimes feel more like this:

10. Representing Psychiatry, I am here to tell you: • Thank you for your dedication, your attention, your focus, your power to heal and to guide many thousands of human beings toward health and safety. • We really appreciate everything you do. • Without you, Kaiser would not exist, and many lives would crumble into chaos.

11. So if there are only 20 of us,how can we support you? • Phone Consults via eConsult • Monday – Friday 8:30 AM to 5:00 PM a psychiatrist is holding a cell phone waiting for your call. Immediate Access. For medication questions, call 916-973-4888. • For Crisis/Urgent appts, call the COD line directly at 916-973-7697 (suicidal, homicidal, psychotic, or need same/next day appt).

12. Immediate Access? • You have a depressed patient in your office. You’ve tried Prozac and Celexa and both failed. Instead of telling pt to call psychiatry, pick up the phone and call right there with the patient in your room. A psychiatrist answers the phone. Discuss, address issues, come up with a tx plan, implement.

13. Robbie Pearl calls it the “Wow factor!”

14. How to get there. • Push the eConsult button • Facility: Sacramento • Specialty: Adult Psychiatry • Problem/Reason: “Other” • This pulls up the Phone Consult screen.

16. So let’s give you some psychiatric muscle for you patients with mental illness

17. Trying to diagnose psych patients can feel like

18. Keep it simple. Just what the heck is Bipolar Disorder?

19. Multiple types/multiple episodes within types • Bipolar I Disorder • Bipolar II Disorder • Major Depressive Episode • Manic Episode • Mixed Episode • Hypomanic Episode

20. C. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the person when not symptomatic. • D. The disturbance in mood and the change in functioning are observable by others. • E. The episode is not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization, and there are no psychotic features. • F. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism). • Note: Hypomanic-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar II Disorder.

21. Oh, and there are “specifiers” too: • Specifiers • The following specifiers for Bipolar I Disorder can be used to describe the current Manic, Mixed, or Major Depressive Episode (or, if criteria are not currently met for a Manic, Mixed, or Major Depressive Episode, the recent Manic, Mixed, or Major Depressive Episode): •          Mild, Moderate, Severe Without Psychotic Features, Severe With Psychotic Features, In Partial Remission, In Full Remission...          With Catatonic Features...          With Postpartum Onset... •          The following specifiers apply only to the current (or most recent) Major

22. Depressive Episode only if it is the most recent type of mood episode: •   Chronic...           With Melancholic Features...           With Atypical Features... • The following specifiers can be used to indicate the pattern of episodes: • Longitudinal Course Specifiers (With or Without Full Interepisode Recovery)...             With Seasonal Pattern (applies only to the pattern of Major Depressive Episodes)...             With Rapid Cycling...

23. So you ready? Apply all that to:

24. Diagnostic Criteria for a Manic Episode (DSM-IV-TR) • A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary). • During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree: • inflated self-esteem or grandiosity • decreased need for sleep (e.g., feels rested after only 3 hours of sleep) • more talkative than usual or pressure to keep talking • flight of ideas or subjective experience that thoughts are racing • distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli) • increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation • excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments) • The symptoms do not meet criteria for a Mixed Episode. • The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features. • The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).

25. Diagnostic Criteria for a Major Depressive Episode (DSM-IV-TR) • Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) or (2). • depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). Note: In children and adolescents, can be irritable mood. • markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others) • significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains. • Insomnia or Hypersomnia nearly every day • psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down) • fatigue or loss of energy nearly every day • feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick) • diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others) • recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide • The symptoms do not meet criteria for a Mixed Episode. • The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. • The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism). • The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.

26. Diagnostic Criteria for a Hypomanic Episode (DSM-IV-TR) • A distinct period of persistently elevated, expansive, or irritable mood, lasting throughout at least 4 days, that is clearly different from the usual non depressed mood. • During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree: • inflated self-esteem or grandiosity • decreased need for sleep (e.g., feels rested after only 3 hours of sleep) • more talkative than usual or pressure to keep talking • flight of ideas or subjective experience that thoughts are racing • distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli) • increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation • excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., the person engages in unrestrained buying sprees, sexual indiscretions, or foolish business investments) • The episode is associated with an unequivocal change in functioning that is uncharacteristic of the person when not symptomatic. • The disturbance in mood and the change in functioning are observable by others. • The episode is not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization, and there are no psychotic features. • The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).

27. Diagnostic Criteria for a Mixed Episode (DSM-IV-TR) • The criteria are met both for a Manic Episode and for a Major Depressive Episode (except for duration) nearly every day during at least a 1-week period. • The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features. • The symptoms are not due to the direct physiological effects of a substance (e.g., a illicit drugs, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).

28. Anybody bored yet?

29. How’s the gyroscope?

30. So let’s get real. Let’s play: “I can name that mood disorder in 5 lines.”

31. Take a piece of paper and draw three horizontal lines.

32. ___________________________________ ___________________________________ ___________________________________

33. Write the words: Manic, Normal, Depressed

34. _______________Manic______________ _______________Normal______________ ______________Depressed____________

35. Add a line in the middle of your other lines.

36. _______________Manic______________ _______________Normal______________ ______________Depressed____________

37. Write the words: Hypomanic Dysthymic

38. _______________Manic______________ Hypomanic _______________Normal______________ Dysthymic ______________Depressed____________

39. Manic Normal Depressed Hypomanic Dysthymic

40. Manic Money Ass to Everybody Nothing is Neutral Impulsive Cyclical Normal Depressed Demented cognition Everything is affected Personal hygiene Regressed Suicidal Septic Energy vacuum Death/morbid thoughts Hypo Half the mania Yearning for greatness but still in control People’s opinions still matter Organized enough to work/function Dysthymic Determined to see Negative “Yes, butt….” Serious Time is 2 yrs Haggard “Yesterday….” Interested but little joy Melancholic Ill Cynical

41. Manic Normal Depressed Normal Hypomanic Dysthymic

42. Manic Normal Depressed Major Depressive Disorder Hypomanic Dysthymic

43. Manic Normal Depressed Cyclothymic Disorder Hypomanic Dysthymic

44. Manic Normal Depressed Bipolar II Hypomanic Dysthymic

45. Manic Normal Depressed Bipolar I Hypomanic Dysthymic

46. Manic Normal Depressed Bipolar I Hypomanic Dysthymic

47. Manic Normal Depressed Borderline Personality Disorder (each shift triggered by external forces) Hypomanic Dysthymic

48. Some Pearls

49. Mood Interview Pearl #1 Origin “When were you first aware of these feelings? At what age?”

50. Age of Onset and Gender Issues