Bipolar and Depression Assessment and Treatment
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This document discusses bipolar disorder and depression. It provides information on diagnosing and differentially diagnosing bipolar disorder and depression. It covers the goals of treatment, which include preventing relapse and improving functioning. Medication and psychosocial interventions are discussed as core treatment approaches, along with managing side effects and enhancing treatment compliance. The needs of specific populations like children, adolescents, and the elderly are also addressed.
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Bipolar and Depression Assessment and Treatment
- 1. Bipolar and Depression Dr. Dawn-Elise Snipes PhD, LMHC Executive Director, AllCEUs.com Copyright AllCEUs Unlimited CEUs $59 | Specialty Certificate Training $89 | Webinars $5
- 2. Objectives Differentially Diagnose Bipolar Disorder and Depression Recognize general medical conditions and drugs that may mimic depression or mania Understand the goals of psychiatric management of bipolar disorder and depression Identify bipolar patients at increased risk of suicide Understand the link between bipolar disorder and substance abuse Identify key areas of consideration when making a treatment placement decision Learn about the areas which patients with bipolar disorder and their families may need education Familiarize with the most common psychopharmacological interventions for bipolar disorder Copyright AllCEUs Unlimited CEUs $59 | Specialty Certificate Training $89 | Webinars $5
- 3. Bipolar I and II Bipolar I disorder: at least one episode can be characterized as mania Episodic, lifelong illness with a variable course The first episode may be manic, hypomanic, mixed, or depressive Patients may experience several episodes of depression before a manic episode Biploar II has depressive episodes but no mania. Copyright AllCEUs Unlimited CEUs $59 | Specialty Certificate Training $89 | Webinars $5
- 4. Differential Diagnosis Ask about a history of depression accompanied or followed by manic or hypomanic symptoms Assess for substance use disorder, other general medical conditions or medications Medical conditions associated with manic- like symptoms include: Multiple sclerosis Lesions closely linked to the limbic system Hyper or hypothyroid Head injuries Encephalitis Copyright AllCEUs Unlimited CEUs $59 | Specialty Certificate Training $89 | Webinars $5
- 5. Medications Associated with Manic- like Symptoms L-Dopa Corticosteroids High-dose decongestants Stimulants (weight loss, ADHD) Antidepressants may trigger a manic episode Copyright AllCEUs Unlimited CEUs $59 | Specialty Certificate Training $89 | Webinars $5
- 6. Substance Use May cause manic-like episodes May help patient self-medicate Stimulants (manic like symptoms) Cocaine Methamphetamines/Amphetamines Ephedrine Ecstasy/MDMA Caffeine Copyright AllCEUs Unlimited CEUs $59 | Specialty Certificate Training $89 | Webinars $5
- 7. Patients with Bipolar Seek treatment during depressive episodes Rarely volunteer information about manic or hypomanic symptoms Do not see the symptoms of hypomania to be distressing Copyright AllCEUs Unlimited CEUs $59 | Specialty Certificate Training $89 | Webinars $5
- 8. Suicide Completed suicide rates 10% to 15% Suicide attempts associated with depressive episodes or depressive features of mixed episodes Ask every patient about suicidal ideation Copyright AllCEUs Unlimited CEUs $59 | Specialty Certificate Training $89 | Webinars $5
- 9. Increased Risk Factors Factors associated with increased risk: Means Lethality Family history of suicide Pervasive insomnia Impulsiveness Psychiatric comorbidity Psychosis Personality disorder Lack of social support Copyright AllCEUs Unlimited CEUs $59 | Specialty Certificate Training $89 | Webinars $5
- 10. Hospitalization Patients who: Pose a serious threat of harm to themselves Are severely ill Lack adequate social support Demonstrate significantly impaired judgment Have complicating psychiatric or general medical conditions Have not responded adequately to outpatient treatment. Re-evaluate treatment setting regularly Copyright AllCEUs Unlimited CEUs $59 | Specialty Certificate Training $89 | Webinars $5
- 11. Education Should introduce facts about the illness and its treatment Use printed, verbal and videotaped material Present in an ongoing gradual and consistent process Use psychoeducational groups Copyright AllCEUs Unlimited CEUs $59 | Specialty Certificate Training $89 | Webinars $5
- 12. Stressors Commonly precede episodes Disrupted sleep-wake cycles may specifically trigger manic episodes Physical illnesses that cause changes in eating and/or dehydration Alter blood plasma levels May require dose adjustment Regular patterns should be promoted Copyright AllCEUs Unlimited CEUs $59 | Specialty Certificate Training $89 | Webinars $5
- 13. Counselor Activities Preplanning Plan for impairments in functioning Assisting patient in scheduling absences from work Avoid major life changes Plan for the needs of their children while the patient is in an acute state Assist the patient who is able to work in contacting vocational rehab Assist the patient in linking with a case manager and/or services Copyright AllCEUs Unlimited CEUs $59 | Specialty Certificate Training $89 | Webinars $5
- 14. Medication Severe mania or mixed episodes: Antipsychotic and valproate or lithium Mild to moderate mania or mixed episodes: Monotherapy with an antipsychotic, valproate or lithium Short-term adjunctive treatment with a benzodiazepine may be helpful Mixed episodes: Certain drugs preferred over lithium Atypical antipsychotics preferred over typical antipsychotics Copyright AllCEUs Unlimited CEUs $59 | Specialty Certificate Training $89 | Webinars $5
- 15. Antidepressants Use earlier for bipolar II depression than for bipolar I Patients with bipolar II disorder have lower rates of antidepressant induced switching into hypomania or mania Antidepressants may increase mood cycling Recommended to combine mood stabilizer with antidepressant Copyright AllCEUs Unlimited CEUs $59 | Specialty Certificate Training $89 | Webinars $5
- 16. Electroconvulsive Therapy (ECT) May be considered for: Patients who are severely ill Whose mania or depression is treatment resistant Who experience symptoms during pregnancy Copyright AllCEUs Unlimited CEUs $59 | Specialty Certificate Training $89 | Webinars $5
- 17. Goals of Treatment Prevent relapse and recurrence Reduce cycling frequency and subthreshold symptoms Reduce suicide risk Improve overall functioning Copyright AllCEUs Unlimited CEUs $59 | Specialty Certificate Training $89 | Webinars $5
- 18. Psychosocial Interventions Address: Illness management Treatment Triggers Relapse Prevention Interpersonal difficulties Coping skills and distress tolerance Cognitive distortions Wellness behaviors and vulnerability prevention Copyright AllCEUs Unlimited CEUs $59 | Specialty Certificate Training $89 | Webinars $5
- 19. Enhance Treatment Compliance Assess potential barriers: Lack of motivation or excessive pessimism; side effects of treatment; problems in the therapeutic relationship; and logistical, economic, or cultural barriers to treatment. Collaborate with the patient (and, if possible, the family) to min-imize barriers. Encourage the patient to articulate concerns about treatment or its side effects, and consider the patient’s preferences for treatment Recognize that during the acute phase, depressed patients may be poorly motivated and unduly pessimistic and may suffer deficits of memory. Copyright AllCEUs Unlimited CEUs $59 | Specialty Certificate Training $89 | Webinars $5
- 20. Enhance Treatment Compliance During the maintenance phase, euthymic patients may undervalue the benefits and focus on the burdens of treatment. In patients who prefer complementary and alternative thera-pies, S-adenosyl methionine (SAMe) or St. John’s wort might be considered, although evidence for their efficacy is modest, and careful attention to drug-drug Bright light therapy may be considered to treat seasonal affective disorder as well as nonseasonal depression. Copyright AllCEUs Unlimited CEUs $59 | Specialty Certificate Training $89 | Webinars $5
- 21. Enhance Compliance… Promote awareness patterns of activity and sleep Work with the patient to anticipate and address early signs of relapse Evaluate and manage functional impairment Copyright AllCEUs Unlimited CEUs $59 | Specialty Certificate Training $89 | Webinars $5
- 22. Side Effects Bruxism Activation or sedation Headaches (assess etiology and treat) Medications used for migraine treatment, called triptans, and SSRIs both increase the brain chemical serotonin. Serotonin syndrome, which causes flushing, rapid heart rate, and headache, can occur if these medications are taken together. Nausea Divided doses Administer with food Weight gain Evaluate causes Bupropion (not in people with a hx of ED) Copyright AllCEUs Unlimited CEUs $59 | Specialty Certificate Training $89 | Webinars $5
- 23. Side Effects Sexual Side Effects Bupropion (Wellbutrin XL, Wellbutrin SR, Aplenzin, Forfivo XL) a norepinephrine-dopamine reuptake inhibitor (NDRI) Mirtazapine (Remeron) atypical antidepressant; typically increases appetite Dry Mouth Suicidal ideation Sleep disturbances (nightmares, sleepwalking, easily waking) Constipation https://psychiatryonline.org/pb/assets/raw/sitew ide/practice_guidelines/guidelines/mdd-guide.pdf Copyright AllCEUs Unlimited CEUs $59 | Specialty Certificate Training $89 | Webinars $5
- 24. Postpartum Period Associated with increased risk for relapse into mania, depression, psychosis Rate of postpartum relapse is as high as 50% Copyright AllCEUs Unlimited CEUs $59 | Specialty Certificate Training $89 | Webinars $5
- 25. Prevalence in Children and Adolescents 1% Additional 5% to 6% have mood symptoms NOS Children with bipolar disorder often have: Mixed mania Rapid cycling Psychosis Often comorbid with attention deficit and conduct disorders Copyright AllCEUs Unlimited CEUs $59 | Specialty Certificate Training $89 | Webinars $5
- 26. Prevalence in Children and Adolescents Children and teens having a manic episode may: Feel very happy or act silly in a way that's unusual Have a very short temper Talk really fast about a lot of different things Have trouble sleeping but not feel tired Have trouble staying focused Talk and think about sex more often Do risky things. Copyright AllCEUs Unlimited CEUs $59 | Specialty Certificate Training $89 | Webinars $5
- 27. Prevalence in Children and Adolescents Children and teens having a depressive episode may: Feel very sad Complain about pain a lot, like stomachaches and headaches Sleep too little or too much Feel guilty and worthless Eat too little or too much Have little energy and no interest in fun activities Think about death or suicide. Copyright AllCEUs Unlimited CEUs $59 | Specialty Certificate Training $89 | Webinars $5
- 28. Elderly In patients over 65 years of age, prevalence rates of bipolar disorder range from 0.1% to 0.4% Most manic symptoms are due to a general medical condition or medication Copyright AllCEUs Unlimited CEUs $59 | Specialty Certificate Training $89 | Webinars $5
- 29. Summary Bipolar can be diagnosed in children, adults and elderly Wide range of medications effective in treatment Psychosocial interventions focus on minimizing stress and increasing routines Copyright AllCEUs Unlimited CEUs $59 | Specialty Certificate Training $89 | Webinars $5
Editor's Notes
- Times for a mini mental status include missed/cancelled appointments, calling office in crisis, scheduled appointments
- Means: access to Lethality of means Family history of suicide Pervasive insomnia often leads to poor decision making and/or self medication to sleep (if not part of a manic episode) Impulsiveness (while under the influence of substances or when in a manic episode) Psychiatric comorbidity (anxiety, schizophrenia, addiction) Psychosis (especially with command hallucinations) Personality disorder (especially Borderline) Lack of social support (no stress buffer, easier to withdraw and disappear)
- Pose a serious threat of harm to themselves (lack of self care, combining meds with illicit drugs or alcohol) Are severely ill with complicating psychiatric or general medical conditions (mentally or physically) Lack adequate social support Demonstrate significantly impaired judgment Have not responded adequately to outpatient treatment
- Patient Handouts http://www.nimh.nih.gov/health/publications/index.shtml Bipolar Disorder in Children and Teens (Easy to Read) http://www.nimh.nih.gov/health/publications/bipolar-disorder-in-children-and-teens-easy-to-read.shtml Bipolar Disorder (Easy to Read) http://www.nimh.nih.gov/health/publications/bipolar-disorder-easy-to-read.shtml Group topics Adjusting to the reality of the illness the predictable reactions of patients who learn that they have a chronic, recurrent, and potentially life-threatening illness. These reactions are denial, anger, ambivalence, and anxiety, all of which must be approached in psychotherapy. Loss Patients must be helped to deal with their psychological reactions to loss, including loss of relationships, loss of employment, and loss of self-esteem. The effect of bipolar illness on marriages, children's well-being, and extended family relationships is often devastating and seemingly irreversible. Compliance Compliance with an informed treatment plan that includes medications and other forms of treatment requires the development of a working alliance with the patient
- Emotional or physical stressors commonly precede episodes Many physical illnesses lead to changes in eating, diarrhea or vomiting all of which can affect medication effectiveness and dosage. Additionally, the use of antihistamines or decongestants with many psychotropics can have unintended consequences. Family visits, holiday gatherings, anniversaries of trauma, death of a loved one or pet, changing jobs, moving and many other stressors can be sufficient to trigger an episode. Disrupted sleep-wake cycles may specifically trigger manic episodes. Traveling/jet lag, new baby in the house, particularly rainy days that disrupt circadian rhythms, Regular patterns should be promoted including sleeping, eating, daily activity… Work with the person’s temperament. If they like to be a bit spontaneous, or to sleep in every once in a while, talk about how to work that in (day trips might involve packing an extra dose of medication in case they have car trouble or decide to stay overnight, identifying things that might be stressful on a trip---wondering if they forgot to unplug the iron, worrying about their pet if they are gone longer than expected, heavy traffic, long lines like at Disney…) None of these stressors is insurmountable, but the person should be aware of them and their solutions. If they prefer to be very structured, then so much the easier.
- Preplanning Plan for impairments in functioning---when meds need to be adjusted, if there is an acute crisis that precipitates an event Assisting patient in scheduling absences from work—have the phone number and contact person available for the patient or caregiver Avoid major life changes during the episode if possible (marriage, divorce, moving) Plan for the needs of their children while the patient is in an acute state (care, school, medical records, birth certificate, social security card and health insurance) Assist the patient who is able to work in contacting vocational rehab if necessary and becoming familiar with the ADA to understand and be able to ask for reasonable accommodations Assist the patient in linking with a case manager and/or services as needed: housing, transportation, food stamps, insurance, financial planning (co-signers),
- Mood Stabilizers Lithium, the first mood-stabilizing medication approved by the U.S. Food and Drug Administration (FDA) for treatment of mania, is often very effective in controlling mania and preventing the recurrence of both manic and depressive episodes. Anticonvulsant medications, such as valproate (Depakote®) or carbamazepine (Tegretol®), also can have mood-stabilizing effects and may be especially useful for difficult-to-treat bipolar episodes. Valproate was FDA-approved in 1995 for treatment of mania. Newer anticonvulsant medications, including lamotrigine (Lamictal®), gabapentin (Neurontin®), and topiramate (Topamax®), are being studied to determine how well they work in stabilizing mood cycles. Anticonvulsant medications may be combined with lithium, or with each other, for maximum effect. Children and adolescents with bipolar disorder generally are treated with lithium, but valproate and carbamazepine also are used. Researchers are evaluating the safety and efficacy of these and other psychotropic medications in children and adolescents. There is some evidence that valproate may lead to adverse hormone changes in teenage girls and polycystic ovary syndrome in women who began taking the medication before age 20.13 Therefore, young female patients taking valproate should be monitored carefully by a physician. Women with bipolar disorder who wish to conceive, or who become pregnant, face special challenges due to the possible harmful effects of existing mood stabilizing medications on the developing fetus and the nursing infant.14 Therefore, the benefits and risks of all available treatment options should be discussed with a clinician skilled in this area. New treatments with reduced risks during pregnancy and lactation are under study.
- Mood Stabilizers Atypical antipsychotic medications, including clozapine (Clozaril®), olanzapine (Zyprexa®), risperidone (Risperdal®), quetiapine (Seroquel®), and ziprasidone (Geodon®), are being studied as possible treatments for bipolar disorder. Evidence suggests clozapine may be helpful as a mood stabilizer for people who do not respond to lithium or anticonvulsants.16 Other research has supported the efficacy of olanzapine for acute mania, an indication that has recently received FDA approval.17 Olanzapine may also help relieve psychotic depression.18 Aripiprazole (Abilify) is another atypical antipsychotic medication used to treat the symptoms of schizophrenia and manic or mixed (manic and depressive) episodes of bipolar I disorder. Aripiprazole is in tablet and liquid form. An injectable form is used in the treatment of symptoms of agitation in schizophrenia and manic or mixed episodes of bipolar I disorder. Olanzapine may also help relieve psychotic depression.19 If insomnia is a problem, a high-potency benzodiazepine medication such as clonazepam (Klonopin®) or lorazepam (Ativan®) may be helpful to promote better sleep. However, since these medications may be habit-forming, they are best prescribed on a short-term basis. Other types of sedative medications, such as zolpidem (Ambien®), are sometimes used instead.
- Prevent relapse and recurrence Reduce cycling frequency and subthreshold symptoms. Reduce suicide risk Improve overall functioning: emotionally, mentally, physically (reduce aches and pains, lethargy, constipation, improve immunity) , socially, occupationally
- Factors Associated with Postpartum Relapse Change in medications Lack of sleep/irregular sleep wake cycles Hormone changes Weight changes Lack of support PTSD triggered by childbirth The “window” can be anywhere from the beginning of pregnancy (especially if meds are changed or discontinued) through 9 months after the cessation of breast feeding Young children’s irregular sleep-wake cycles can be an added stress for the first couple of years.
- Mood episodes last a week or two—sometimes longer. During an episode, the symptoms last every day for most of the day. Mood episodes are intense. The feelings are strong and happen along with extreme changes in behavior and energy levels. Children and teens having a manic episode may: Feel very happy or act silly in a way that's unusual Have a very short temper Talk really fast about a lot of different things Have trouble sleeping but not feel tired Have trouble staying focused Talk and think about sex more often Do risky things. Children and teens having a depressive episode may: Feel very sad Complain about pain a lot, like stomachaches and headaches Sleep too little or too much Feel guilty and worthless Eat too little or too much Have little energy and no interest in fun activities Think about death or suicide.
- Mood episodes last a week or two—sometimes longer. During an episode, the symptoms last every day for most of the day. Mood episodes are intense. The feelings are strong and happen along with extreme changes in behavior and energy levels. Children and teens having a manic episode may: Feel very happy or act silly in a way that's unusual Have a very short temper Talk really fast about a lot of different things Have trouble sleeping but not feel tired Have trouble staying focused Talk and think about sex more often Do risky things. Children and teens having a depressive episode may: Feel very sad Complain about pain a lot, like stomachaches and headaches Sleep too little or too much Feel guilty and worthless Eat too little or too much Have little energy and no interest in fun activities Think about death or suicide.
- Mood episodes last a week or two—sometimes longer. During an episode, the symptoms last every day for most of the day. Mood episodes are intense. The feelings are strong and happen along with extreme changes in behavior and energy levels. Children and teens having a manic episode may: Feel very happy or act silly in a way that's unusual Have a very short temper Talk really fast about a lot of different things Have trouble sleeping but not feel tired Have trouble staying focused Talk and think about sex more often Do risky things. Children and teens having a depressive episode may: Feel very sad Complain about pain a lot, like stomachaches and headaches Sleep too little or too much Feel guilty and worthless Eat too little or too much Have little energy and no interest in fun activities Think about death or suicide.
- elderly bipolar manic patients have deficits in executive functioning compared with NC samples and provide evidence that the executive deficits demonstrated by bipolar manic elders can be more severe than those in unipolar depressed elders.