bipolar disorder: detection and management in primary care

1. Bipolar Disorder: Detection and Management in Primary Care

2. Disclosures

3. Cain et al, 2005 The Dirt on Coming Clean: Perverse Effects of Disclosing Conflicts of Interest

4. Diagnosis Screen everyone before antidepressants because they can cause: Switch to mania Rapid cycling Rx-resistance Suicide (And FDA says so�) Tools: Bipolarity Index, MoodCheck, PsychEducation.org Treatment Non-medication components of treatment substance use / regular sleep pattern psychotherapy: stress management, support bipolar-specific therapies Mood stabilizers (with antidepressant effects) 9 antidepressants that aren�t antidepressants

5. Diagnosis Screen everyone before antidepressants because they can cause: Switch to mania Rapid cycling Rx-resistance Suicide (And FDA says so�) Tools: Bipolarity Index, MoodCheck, PsychEducation.org Treatment Non-medication components of treatment substance use / regular sleep pattern psychotherapy: stress management, support bipolar-specific therapies Mood stabilizers (with antidepressant effects) 9 antidepressants that aren�t antidepressants

11. Time Symptomatic

13. Mood Spectrum

14. Mood Spectrum

16. Bipolarity Index �How bipolar are you?�

17. Bipolarity Index �How bipolar are you?� Hypomania/Mania 20 points Family History 20 points Age of (Mood) Onset 20 points Course of Illness 20 points Response to Rx 20 points

18. Diagnosis Screen everyone before antidepressants because they can cause: Switch to mania Rapid cycling Rx-resistance Suicide (And FDA says so�) Tools: Bipolarity Index, MoodCheck, PsychEducation.org Treatment Non-medication components of treatment substance use / regular sleep pattern psychotherapy: stress management, support bipolar-specific therapies Mood stabilizers (with antidepressant effects) 9 antidepressants that aren�t antidepressants

19. Bipolar Screening Mood Disorders Questionnaire - Better for Bipolar I - Now copyrighted

21. Diagnosis Screen everyone before antidepressants because they can cause: Switch to mania Rapid cycling Rx-resistance Suicide (And FDA says so�) Tools: Bipolarity Index, MoodCheck, PsychEducation.org Treatment Non-medication components of treatment substance use / regular sleep pattern psychotherapy: stress management, support bipolar-specific therapies Mood stabilizers (with antidepressant effects) 9 antidepressants that aren�t antidepressants

22. Diagnosis Over or under-diagnosis? FDA: �Screen for Bipolar� Beyond the DSM-IV: non-manic bipolar markers Tools: Bipolarity Index, PsychEducation.org, MoodCheck Treatment Non-medication components of treatment substance use / regular sleep pattern psychotherapy: stress mgm�t, support bipolar-specific therapies Mood stabilizers (with antidepressant effects) Antidepressants in bipolar depression? 9 antidepressants that aren�t antidepressants

24. Diagnosis Over or under-diagnosis? FDA: �Screen for Bipolar� Beyond the DSM-IV: non-manic bipolar markers Tools: Bipolarity Index, PsychEducation.org, MoodCheck Treatment Non-medication components of treatment substance use / regular sleep pattern psychotherapy: stress mgm�t, support bipolar-specific therapies Mood stabilizers (with antidepressant effects) Antidepressants in bipolar depression? 9 antidepressants that aren�t antidepressants

28. Diagnosis Screen everyone before antidepressants because they can cause: Switch to mania Rapid cycling Rx-resistance Suicide (And FDA says so�) Tools: Bipolarity Index, MoodCheck, PsychEducation.org Treatment Non-medication components of treatment substance use / regular sleep pattern psychotherapy: stress management, support bipolar-specific therapies Mood stabilizers (with antidepressant effects) 9 antidepressants that aren�t antidepressants

29. Disclosures

30. TIMA Bipolar: Treatment of Acute Depressive Episodes (Stages 1�2) This slide represents the algorithm developed through the Texas Implementation of Medication Algorithms initiative for depressive episodes in patients with bipolar I disorder. This particular algorithm is a standalone guideline, distinct from those for treating patients with mania, hypomania, or mixed episodes. Depression treatments were ordered with the least likelihood of causing mood destabilization. Stage 1 has multiple entry points. All patients with bipolar disorder who are currently depressed should have mood stabilizer treatment (eg, lithium) optimized before initiation of antidepressants. If depressive symptoms persist after mood stabilizer treatment is optimized, lamotrigine (LTG) should be added. LTG should be used as monotherapy only in patients with no history of severe and/or recent mania. Stage 2 options include olanzapine-fluoxetine combination treatment and atypical antipsychotics with evidence of antidepressive activity. After partial response or nonresponse after stage 2, further medical consult or referral for other treatment options is suggested. Reference Suppes T, Dennehy EB, Hirschfeld RM, et al. The Texas implementation of medication algorithms: update to the algorithms for treatment of bipolar I disorder. J Clin Psychiatry. 2005;66:870-886. TIMA Bipolar: Treatment of Acute Depressive Episodes (Stages 1�2) This slide represents the algorithm developed through the Texas Implementation of Medication Algorithms initiative for depressive episodes in patients with bipolar I disorder. This particular algorithm is a standalone guideline, distinct from those for treating patients with mania, hypomania, or mixed episodes. Depression treatments were ordered with the least likelihood of causing mood destabilization. Stage 1 has multiple entry points. All patients with bipolar disorder who are currently depressed should have mood stabilizer treatment (eg, lithium) optimized before initiation of antidepressants. If depressive symptoms persist after mood stabilizer treatment is optimized, lamotrigine (LTG) should be added. LTG should be used as monotherapy only in patients with no history of severe and/or recent mania. Stage 2 options include olanzapine-fluoxetine combination treatment and atypical antipsychotics with evidence of antidepressive activity. After partial response or nonresponse after stage 2, further medical consult or referral for other treatment options is suggested. Reference Suppes T, Dennehy EB, Hirschfeld RM, et al. The Texas implementation of medication algorithms: update to the algorithms for treatment of bipolar I disorder. J Clin Psychiatry. 2005;66:870-886.

31. Texas� Bipolar Depression Algorithm TIMA Bipolar: Treatment of Acute Depressive Episodes (Stages 1�2) This slide represents the algorithm developed through the Texas Implementation of Medication Algorithms initiative for depressive episodes in patients with bipolar I disorder. This particular algorithm is a standalone guideline, distinct from those for treating patients with mania, hypomania, or mixed episodes. Depression treatments were ordered with the least likelihood of causing mood destabilization. Stage 1 has multiple entry points. All patients with bipolar disorder who are currently depressed should have mood stabilizer treatment (eg, lithium) optimized before initiation of antidepressants. If depressive symptoms persist after mood stabilizer treatment is optimized, lamotrigine (LTG) should be added. LTG should be used as monotherapy only in patients with no history of severe and/or recent mania. Stage 2 options include olanzapine-fluoxetine combination treatment and atypical antipsychotics with evidence of antidepressive activity. After partial response or nonresponse after stage 2, further medical consult or referral for other treatment options is suggested. Reference Suppes T, Dennehy EB, Hirschfeld RM, et al. The Texas implementation of medication algorithms: update to the algorithms for treatment of bipolar I disorder. J Clin Psychiatry. 2005;66:870-886. TIMA Bipolar: Treatment of Acute Depressive Episodes (Stages 1�2) This slide represents the algorithm developed through the Texas Implementation of Medication Algorithms initiative for depressive episodes in patients with bipolar I disorder. This particular algorithm is a standalone guideline, distinct from those for treating patients with mania, hypomania, or mixed episodes. Depression treatments were ordered with the least likelihood of causing mood destabilization. Stage 1 has multiple entry points. All patients with bipolar disorder who are currently depressed should have mood stabilizer treatment (eg, lithium) optimized before initiation of antidepressants. If depressive symptoms persist after mood stabilizer treatment is optimized, lamotrigine (LTG) should be added. LTG should be used as monotherapy only in patients with no history of severe and/or recent mania. Stage 2 options include olanzapine-fluoxetine combination treatment and atypical antipsychotics with evidence of antidepressive activity. After partial response or nonresponse after stage 2, further medical consult or referral for other treatment options is suggested. Reference Suppes T, Dennehy EB, Hirschfeld RM, et al. The Texas implementation of medication algorithms: update to the algorithms for treatment of bipolar I disorder. J Clin Psychiatry. 2005;66:870-886.

32. Lamotrigine: Rash Onset

33. (Vulcan Thumb)

35. Diagnosis Screen everyone before antidepressants because they can cause: Switch to mania Rapid cycling Rx-resistance Suicide (And FDA says so�) Tools: Bipolarity Index, MoodCheck, PsychEducation.org Treatment Non-medication components of treatment substance use / regular sleep pattern psychotherapy: stress management, support bipolar-specific therapies Mood stabilizers (with antidepressant effects) 9 antidepressants that aren�t antidepressants

36. 1. Cause switching? How often? 2. Mood destabilization a) Cause rapid cycling, mixed states b) Prevent stabilization? c) Cause �kindling�? 3. Already on, and a mood stabilizer, and doing well � when to taper off? Leave on?

37. 1. Cause switching? How often? 2. Mood destabilization a) Cause rapid cycling, mixed states b) Prevent stabilization? c) Cause �kindling�? 3. Already on, and a mood stabilizer, and doing well � when to taper off? Leave on?