Transcript Introduction to Working with the Asian Patient in Primary Care
Common (Complex) Problems in Psychiatry: A Case-Based Approach Focus on Mood Disorders and Suicide
Descartes Li, M.D.
Associate Professor of Clinical Psychiatry University of California, San Francisco
Major Depressive Disorder Dysthymic Disorder “UNIPOLAR” “BIPOLAR” Cyclothymic Disorder Bipolar I Disorder Bipolar II Disorder
Bipolar Spectrum Disorders
Frequently patients may present with psychiatric symptoms, but do not appear to fulfill criteria for bipolar disorder.
They frequently present with diagnosable depressive episodes, severe anxiety, or substance abuse. However, they do not respond well to antidepressants.
Bipolar Spectrum Disorders:
Additional clues to diagnosis Family history of bipolar disorder Seasonal pattern Psychotic major depressive episodes Early age of onset of major depressive episode (<25) Postpartum depression Antidepresssant “wear off” (ie, acute response but lacking in prophylactic efficacy) Lack of response to 3 or more antidepressant treatment trials
Notice
this discussion will likely contain references to off-label uses of FDA approved medications Patients with soft bipolar disorders frequently benefit from treatment with mood stabilizers and/or low-dose atypical neuroleptics.
55yo MWM postal worker
h/o recurrent depressions since age 22, progressively more irritable and depressed for past 6m, insomnia (3-4 hours/night), ruminative thinking about work stressors, ?mildly paranoid thinking? (no manic or fam psych hx) 4m ago, not able to work, rx’d lorazepam 1mg at bedtime somewhat helpful Since then, trials of sertraline 50mg daily for 5 d agitation, insomnia worsened; bupropion 150mg daily for 2 d worsened agitation, insomnia remote h/o fluoxetine amitriptyline insomnia, agitation, remote h/o insomnia, agitation Diagnosis? Management/treatment?
DSM-IV Diagnostic Criteria Mixed Episode:
Rapidly alternating moods (sadness, irritability, euphoria) accompanied by criteria for both a Manic Episode and a Major Depressive Episode.
Duration of 1 week.
Frequently includes agitation, insomnia, appetite dysregulation, psychotic features, and suicidal thinking.
Symptoms are not due to the direct effects of a substance, or a general medical condition.
Importance of differentiating unipolar from bipolar depression: Different treatment pharmacologically!
Antidepressant monotherapy in individuals with bipolar disorder can lead to rapid cycling or mania induction Rapid cycling (greater than 4 mood episodes in one year) is particularly difficult to treat and can lead to poor outcomes.
Mania, in addition to direct consequences, frequently ends in a depressive episode that is even more refractory to treatment.
38yo single Chinese woman with SLE and chronic renal insufficiency
Depressed (“my entire life”)and depressed now (moderately worse past 6m) further hx: 2-3 periods last several months of elevated mood, decreased need for sleep, increased spending, usually in response for some situation (thought a co worker really liked her, or creatinine improved) chronically (past several years) on prednisone 5-10mg daily, reports that a trial of prednisone 20mg daily “Made me delusional”, severe insomnia Diagnosis? Management?
Signs of subsyndromal mania: DIGFAST
D – Distractibility I – Insomnia G – Grandiosity (or inflated self esteem) F – Flight of Ideas (or racing/crowded thoughts) A – Activities (increased goal directed activities) S- Speech (pressured) T- Thoughtlessness (increased pleasurable activities with potential for negative consequences: sex, money, traveling, driving)
Bipolar Disorder Symptoms Are Chronic and Predominantly Depressive 146 Bipolar I Patients followed 12.8 yrs 86 Bipolar II Patients followed 13.4 yrs
1% 2% 9% 6% 46% 32% 53% % of Weeks Asymptomatic Depressed Hypo/manic Cycling/mixed
Study 1 1. Judd LL, et al. 2. Judd LL, et al. Arch Gen Psychiatry Arch Gen Psychiatry 2002.59:530-537.
2003;60:261-269.
50%
Study 2
Treatment Implications -- Medications
Mood stabilizers Mainstay of treatment Usually require lab monitoring Start Lithium carbonate at 300mg qhs Lithium carbonate, Valproate (Depakote), Carbamazepine (Tegretol) Lamotrigine (Lamictal), Topiramate (Topamax), Gabapentin (Neurontin), Oxcarbazepine (Trileptal)
55yo MLF with NIDDM, mildly obese, depressed and anxious chronically
with insomnia alternating with periods of hypersomnia. There is also a question of PTSD, she sometimes hears voices, cries easily during visits previous trials of paxil, venlafaxine, bupr ineffective she is currently on ativan 1mg at bedtime, but still symptomatic, insomnia Please discuss diagnosis and treatment options.
Atypical Antipsychotics
Helpful with agitation, psychotic features, insomnia Less risk of tardive dyskinesia compared with traditional antipsychotics High rate of weight gain, dyslipidemia, hypercholesterolemia, hyperglycemia (start at half tablet of smallest pill qhs, titrate up) Olanzapine (Zyprexa) dosage: 2.5mg-20mg at hs Quetiapine (Seroquel) dosage: 12.5mg-600mg at hs Risperidone (Risperdal) dosage: 0.25mg-6mg at hs or bid Ziprasidone (Geodon) Aripiprazole (Abilify) dosage: 20-160mg a day dosage: 5-30mg a day
24yo SWF waitress dx’d w/ bp do
Currently on lithium carbonate 900mg at bedtime for the past year 3yrs ago, was hosp’d for acute mania, initially treated with risperdal and depakote, but switched to lithium one year ago b/o weight gain no labs for 2 years What laboratory tests do you want?
Lithium Carbonate: a review Side effects: polyuria (nephrogenic diabetes insipidus), hypothyroidism, acne vulgaris (oily skin) Dose dependent, intoxication sx’s (cognitive difficulties/confusion, tremor, ataxia) Labs: pretreatment: CBC, lytes, lfts, creatinine, tft’s and then 5d after changing dosage and q6m: trough lithium level, creatinine, tsh
55yo single, Afr-Am female admin asst, NIDDM and bipolar d/o type I, rather brittle diabetes Psychiatrically stable (ie, no hospitalizations) for past 10yrs on prolixin 1mg at bedtime, divalproex 1500mg at bedtime, diazepam 20-25mg at bedtime Previous doctor retired remote h/o lithium –“I’ll never go back on that stuff What laboratory tests do you want?
Divalproex review(valproate, Depakote):
Side effects: elevated lft’s, thrombocytopenia, weight gain, sedation, rare pancreatitis, ?polycystic ovary syndrome Labs: pretreatment- CBC w platelets, LFT's, pregnancy 5d after dosage changes and q6m -cbc with plts, lfts, weight , pancreatic enzymes prn abd pain, n/v, anorexia
24yo SWF waitress dx’d w/ bp do
Currently on lithium carbonate 900mg at bedtime for the past year “What other treatments besides medications are available for individuals with bipolar disorder?”
Patients with mood disorders should be educated about common triggers of manic or depressive episodes: sleep deprivation, street drugs (particularly amphetamines, cocaine, hallucinogenics), psychosocial stress.
Treatment Implications – psychosocial treatments for bipolar disorder
Cognitive-behavioral therapy Interpersonal psychotherapy Social rhythm therapy Psychoeducation
44yo MWM independent business owner, depressed
for the past 15 years, drinks ½ bottle of wine each evening, but for the past 8-9 months, has had a couple of cocktails before dinner also (other ½ bottle of wine consumed by wife). Upon further questioning, he also describes bouts of increased energy, lots of business trips (confidentially says he had some extramarital “indiscretions” on a few of these trips), decreased need for sleep: “I was a dynamo.” Intermittent depression most of his life.
Does he have bipolar disorder?
41yo married Chinese female flight attendant, stable hep B, hosp’d for mania 3 years ago
doesn’t recall what she was treated with, off meds since. No h/o substance abuse. No kids.
Now presents with one month of increased anxiety, insomnia, depression Appears tearful, distractible, loquacious, ruminative, doesn’t want to see a psychiatrist
Sedative-hypnotics
Useful adjuncts for maintaining sleep-wake cycles N.B. High rates of co-morbid substance abuse in patients with bipolar disorder.
Benzodiazepines: clonazepam (Klonopin), lorazepam (Ativan), temazepam (Restoril) non-benzodiazepines: zolpidem (Ambien), zaleplon (Sonata)
41yo MWF housewife, 2 children (5+2), no prior psych hx,
for the past year, progressively more depressed and irritable, low energy, increased sleep, snapping and yelling at kids (guilty about this) further hx: one summer trip in her 20’s to Europe, elevated mood, sleeping 4-5 hours night, multiple romantic partners (“I had the time of my life”)
41yo MWF housewife, 2 children (5+2), no prior psych hx (previous patient)
citalopram 20mg daily agitated, more irritable: “my mind is going a mile a minute” lithium 900mg at bedtime signficantly improved, not irritable, sleeping normalized, but still low energy Augmented with paxil 20mg euthymic, still somewhat stressed with two children, part-time job, but manageable
68yo MWM
dx’d with bipolar disorder long ago, stable on lithium 600mg twice a day, LL = 1.0
rountine creatinine =
1.6
Discuss your management of this patient Don’t stop lithium acutely (<30d) because of risk of mania inducation
55yo single WM, unemployed
lives in SRO, is on disability for unknown reasons sleeps 12-14 hours per day, minimal activity, rather minimal thought processes has been on haloperidol 10mg q day, cogentin 1mg daily for at least 10 years past 6 months, insomnia, agitation, problems with landlord (?paranoia?) ?what monitoring should occur?
(check labs, check utox, check stressors/collaterals/compliance, increase haldol)
Pearls for Mood Disorders:
If you hear something like mania or hypomania, then it is Don’t miss mixed depressive episodes Think of bipolar disorder if 2 3 AD’s have been tried and they haven’t worked, or they worked transiently and then “pooped out” Watch for hypomania after you start antidepressants Think of concept of target symptoms Individuals with bipolar disorder spend most of time depressed, may have difficulty recalling hypomanias When patient is asymptomatic, cont with acute treatments if possible (keeping in mind diagnosis)
Suicide
Number 3 cause of death in young adults, number 11 over all.
25,000 deaths per year in the U.S.
Almost of third of people who kill themselves visit a physician in the week before they die (More than a half visit a physician in the month before they die).
Most cases do not report suicidal ideation, most are not asked.
Most cases associated with major psychiatric disorder.
Doctors twice as likely to kill themselves as the general population.
44 year-old, divorced, white man
Seen in ED after crashing his car into a telephone pole. Physical examination and routine blood work are unremarkable. On further interview, he acknowledges “Maybe I didn’t want to live any more.”
CASE (Shea) Chronological Assessment of Suicide Events 3) Past events 2) Recent events (two months) 1) Presenting events: what, means, lethality (real or perceived), risk/rescue, intention, when, wills, letter,drugs/etoh, etc. "walk me through step by step" (behavioral incident) 4) Immediate events
Suicide
Evaluate risk factors: Presenting event (fall from height, single passenger MVA, drug OD) Prior h/o suicide attempts Male, living alone Major psychiatric/medical disorder Substance abuse/intoxication Assess hopelessness/depression /mania/hypomania/mixed Still thinking of suicide?
Interview techniques
1) behavioral incident -- scene by scene 2) gentle assumption -- assume pt has done it "gentle": rapport, nonverbal communication. "what other ways have you thought of killing yourself" 3) symptom assumption -- for minimization, suggest high number, 4) denial of the specific --interview strategy for a list, list specific sx -- allow pt to affirm or deny
44 year-old, divorced, white man
Seen in ED after crashing his car into a telephone pole. Physical examination and routine blood work are unremarkable, except for a BAC of 0.10%. On further interview, he acknowledges that he has been thinking about committing suicide, but currently denies any current intent or plan to kill himself.
Can you discharge him from the ED?
Suicide
Before Discharging a patient, Check: 1)
Firearms
and lethal
medications
secured or removed have been 2) A
supportive person
is available 3) A
follow-up appointment
with a mental health professional has been scheduled 4) The patient has the
name and number
of a clinician who can be called in an emergency
Suicide References/Resources
The Practical Art of Suicide Assessment :
by Shawn Christopher Shea , Wiley 2002.
Night Falls Fast: Understanding Suicide
by Kay Redfield Jamison , Vintage Books 2000.
American Foundation for Suicide Prevention www.afsp.org
American Association of Suicidology www.suicidology.org
Resources for Bipolar Disorder
National Organizations: Depression and Bipolar Support Alliance (800-826-3632; www.dbsalliance.org
) National Alliance for the Mentally Ill (NAMI) (800-950-NAMI; www.nami.org
) National Institute of Mental Health Publications ( www.nimh.nih.gov/publicat/bipolar.cfm
)
Resources for Bipolar Disorder
Books: Miklowitz, D. (2002).
The Bipolar Disorder Survival Guide: What you and your family need to know.
New York: Guilford Press.
Mondimore, F. M. (1999).
Bipolar disorder: A guide for patients and families.
Baltimore: Johns Hopkins University Press.
Jamison, K. R. (1995).
An Unquiet Mind.
New York: Knopf.
Solomon, A. (2001).
The Noonday Demon: An Atlas of Depression.
New York: Touchstone.
Styron, W. (1992).
Darkness visible: A Memoir of Madness.
York: Vintage Books.
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