Preload - PeaceHealth · 2015-11-12 · Response to Rx AD-induced hypo/mania (antidepressants: AD) AD loss of response, > 3 AD’s DSM-IV mania criteria Non-Manic Bipolar Markers

Preload

Website, Zyban pdf, tickertape, Moodcheck

Bipolar Disorder in OB-GYN

Jim Phelps, M.D. Samaritan Mental Health

PsychEducation.org

Corvallis, OR

• 8 yrs inpt/outpt, 6 yrs private outpt, 5 yrs. w/ residency

• PsychEducation.org, 2000 – now Free, no stored data

• Book version, McGraw-Hill

Samaritan Health Services

Samaritan Mental Health

Cain et al, 2005

The Dirt on Coming Clean: Perverse Effects of Disclosing Conflicts of Interest

Diagnosis

– Why care? • How common is it? (enough to need to know all this?) • Antidepressants can make bipolar disorder worse • FDA requires formal Bipolar Screening before antidepressants • Outcomes: Help people whom you cannot now help

– Simple, Fast • Bipolar screening tool • Interpreting results • Web-based patient education

Treatment

– Two medications: one to master, one to consider (pregnancy, breastfeeding)

– Non-medication approaches

Diagnosis

– Why care?

• How common is it? (enough to need to know all this?) • Antidepressants can make bipolar disorder worse • FDA requires formal Bipolar Screening before antidepressants • Outcomes: Help people whom you cannot now help

– Simple, Fast • Bipolar screening tool • Interpreting results • Web-based patient education

Treatment

– Two medications: one to master, one to consider

(pregnancy, breastfeeding)

– Non-medication approaches

population prevalence?

Percentage of depressed patients that are “not unipolar”?

1/50 1/20 1/10 1/5 1/4 1/3 1/2

6.7

1.4 “subthreshold”

0.8 0.6

Merikangas, Akiskal, Angst, Kessler, Hirschfeld, et al Arch Gen Psych, 2007

12-month prevalence

6.7

1.4 “subthreshold”

0.8 0.6

Percentage of depressed patients that are “not unipolar”?

1/50 1/20 1/10 1/5 1/4 1/3 1/2

1.8 / (6.7+1.4+0.8+0.6) = 19%

6.7

1.4 “subthreshold”

0.8 0.6

Percentage of depressed patients that are “not unipolar”?

1/50 1/20 1/10 1/5 1/4 1/3 1/2

2.8 / (2.8 + 6.7) = 30%

Diagnosis

– Why care? • How common is it? (enough to need to know all this?) • Antidepressants can make bipolar disorder worse • FDA requires formal Bipolar Screening before antidepressants • Outcomes: Help people whom you cannot now help

– Simple, Fast • Bipolar screening tool • Interpreting results • Web-based patient education

Treatment

– Two medications: one to master, one to consider (pregnancy, breastfeeding)

– Non-medication approaches

Antidepressants can worsen bipolar disorder

1. Switch to mania 2. Induce mixed states 3. Induce “rapid cycling”

4. Destabilizing: rx ineffective? 5. Long-term exacerbation

(“kindling”, “tardive dysphoria”) ?

6. (do they even work?)

32

Antidepressants can worsen bipolar disorder

1. Switch to mania 2. Induce mixed states 3. Induce “rapid cycling”

4. Destabilizing: rx ineffective? 5. Long-term exacerbation

(“kindling”, “tardive dysphoria”) ?

6. (do they even work?)

Antidepressants can worsen bipolar disorder

1. Switch to mania 2. Induce mixed states 3. Induce “rapid cycling”

4. Destabilizing: rx ineffective? 5. Long-term exacerbation

(“kindling”, “tardive dysphoria”) ?

6. (do they even work?)

McElroy et al. Compr Psychiatry, 1995

Why care?

Antidepressants can worsen bipolar disorder

1. Switch to mania 2. Induce mixed states 3. Induce “rapid cycling”

4. Destabilizing: rx ineffective? 5. Long-term exacerbation

(“kindling”)

6. (do they even work?)

Antidepressants can worsen bipolar disorder

1. Switch to mania 2. Induce mixed states 3. Induce “rapid cycling”

4. Destabilizing: rx ineffective? 5. Long-term exacerbation

(“kindling”)

6. (do they even work?)

Fournier, J. C. et al. JAMA 2010;303:47-53.

Unipolar (MDD)

Diagnosis

– Why care? • How common is it? (enough to need to know all this?) • Antidepressants can make bipolar disorder worse • FDA requires formal Bipolar Screening before antidepressants • Outcomes: Help people whom you cannot now help

– Simple, Fast • Bipolar screening tool • Interpreting results • Web-based patient education

Treatment

– Two medications: one to master, one to consider (pregnancy, breastfeeding)

– Non-medication approaches

Antidepressant Prescribing Information

Diagnosis

– Why care? • How common is it? (enough to need to know all this?) • Antidepressants can make bipolar disorder worse • FDA requires formal Bipolar Screening before antidepressants • Outcomes: Help people whom you cannot now help

– Simple, Fast • Bipolar screening tool • Interpreting results • Web-based patient education

Treatment

– Two medications: one to master, one to consider (pregnancy, breastfeeding)

– Non-medication approaches

Diagnosis

– Why care? • How common is it? (enough to need to know all this?) • Antidepressants can make bipolar disorder worse • FDA requires formal Bipolar Screening before antidepressants • Outcomes: Help people whom you cannot now help

– Simple, Fast • Bipolar screening tool • Interpreting results • Web-based patient education

Treatment

– Two medications: one to master, one to consider (pregnancy, breastfeeding)

– Non-medication approaches

Diagnosis

– Why care?

• Antidepressants can make bipolar disorder worse • FDA requires formal Bipolar Screening before antidepressants • Outcomes: Help people whom you cannot now help

– DSM Categories vs. “Bipolar Spectrum”

• Patient presents with depression episodes: unipolar? bipolar? • Review of categories within the continuum • Evidence for smooth distribution • How to treat at various points along the spectrum

– Placing patients on the spectrum

• DSM criteria review • Beyond the DSM: non-manic bipolar markers • Harvard approach: “Bipolarity Index”

– Simple, Fast

• Bipolar Screening tool: MoodCheck • Interpreting results • Website-based patient education

Unhappy Appetite/weight changes

Disturbed sleep Poor concentration

Suicidal ideation Fatigue

depression? bipolar depression?

DSM-IV mania criteria

Unhappy Appetite/weight changes

Disturbed sleep Poor concentration

Suicidal ideation Fatigue

DSM: disprove BP

DSM manic symptoms

1. 2. 3. 4. 5. 6. 7.

DSM-IV mania criteria

DIGFAST

Unhappy Appetite/weight changes

Disturbed sleep Poor concentration

Suicidal ideation Fatigue

DSM: disprove BP

Distractibility Insomnia Grandiosity Flight of Ideas Activity (increased) Speech (pressured) Thoughtlessness

International Society for Bipolar Disorders Committee on Diagnosis, 2008

Non-Manic Bipolar Markers DSM-IV

mania criteria

Mitchell et al. Diagnostic guidelines for bipolar depression. Bipolar Disorders, 2008 Phelps et al. Validity and utility of bipolar spectrum models. Bipolar Disorders, 2008

Mitchell et al. Comparison of depressive episodes in bipolar disorder and in major depressive disorder within bipolar disorder pedigrees. Brit J Psychiatry, 2011

1. Family History BP relative

2. Age of Onset (dep’) 18 – 25; < 18

3. Course of Illness: Number of episodes >10 (many) Duration of episodes 3 mos (short) Markers (psychosis, post-partum; season) Atypical symptoms (↑ eat, ↑ sleep; leaden, rejection)

4. Response to Rx AD-induced hypo/mania (antidepressants: AD) AD loss of response, > 3 AD’s

DSM-IV mania criteria

Non-Manic Bipolar Markers

• Statistically associated with bipolar disorder - family history - outcome • ↑ the probability that depression is bipolar

1. Family History BP relative

2. Age of Onset 18 – 25; < 18

3. Course of Illness: Number of episodes >10 (many) Duration of episodes 3 mos (short) Markers (psychosis, post-partum; season) Atypical symptoms (↑ eat, ↑ sleep; leaden, rejection)

4. Response to Rx AD-induced hypo/mania (antidepressants: AD) AD loss of response, > 3 AD’s

DSM-IV mania criteria

Non-Manic Bipolar Markers (mnemonic)?

WHIPLASHED: A Mnemonic for Recognizing

Bipolar Depression. Ronald Pies, MD. Psychiatric Times, 2007.

1. Family History BP relative

2. Age of Onset 18 – 25; < 18

3. Course of Illness: Number of episodes >10 (many) Duration of episodes 3 mos (short) Markers (psychosis, post-partum; season) Atypical symptoms (↑ eat, ↑ sleep; leaden, rejection)

4. Response to Rx AD-induced hypo/mania (antidepressants: AD) AD loss of response, > 3 AD’s

DSM-IV mania criteria

Non-Manic Bipolar Markers

Bipolarity Index “How bipolar are you?”

Sachs, 2004

Bipolarity Index “How bipolar are you?”

1. Hypomania/Mania 20 points 2. Family History 20 points 3. Age of (Mood) Onset 20 points 4. Course of Illness 20 points 5. Response to Rx 20 points

Sachs, 2004

(website)

What does this mean for treatment?

Pragmatic: how many antidepressants?

2-3 1-2 1 1?? no

Pragmatic: how many antidepressants?

2-3 1-2 1 1?? no

IPT/Social Rhythm Therapy (incl. chrono-rx)

Prodrome Detection / Bipolar-specific CBT

PsychoEducation for pts and families

Family-Focused Therapy

Diagnosis

– Why care? • How common is it? (enough to need to know all this?) • Antidepressants can make bipolar disorder worse • FDA requires formal Bipolar Screening before antidepressants • Outcomes: Help people whom you cannot now help

– Simple, Fast • Bipolar screening tool • Interpreting results • Web-based patient education

Treatment

– Two medications: one to master, one to consider (pregnancy, breastfeeding)

– Non-medication approaches

Bipolar Screening

• No additional time on your part

• Addresses FDA expectations

• Scored by patient ; “positives” directed to further self-education

• Avoids cut-off yes/no interpretations

• Provides the FDA antidepressant warning in plain english

• Scanned in chart = documentation (EMR? public sector)

Bipolar Screening

1. Smith DJ et al, British J Psych, 2011; and others

2. Algorta G et al. Psych Assessment, 2012 July

MoodCheck

Parts A, B: Bipolar Spectrum Diagnostic Scale (BSDS)

Adequate sensitivity/specificity1 Part C: Family history2, other useful stuff

Part D: Non-manic bipolar markers

- Age of onset

- Course of illness

- Response to treatment

Diagnosis

– Why care? • How common is it? (enough to need to know all this?) • Antidepressants can make bipolar disorder worse • FDA requires formal Bipolar Screening before antidepressants • Outcomes: Help people whom you cannot now help

– Simple, Fast • Bipolar screening tool • Interpreting results • Web-based patient education

Treatment

– Two medications: one to master, one to consider (pregnancy, breastfeeding)

– Non-medication approaches

Treatment

– (Why not screen and then refer to Mental Health?)

– Two medications to master • Why these two? Who says? • Low-dose lithium (blood level <0.8) : lithium primer • lamotrigine

– Non-medication component • Who will do basics in house? (diet, exercise, substance use) • Patient education • Regular 7-8 hour sleep in darkness

Treatment

– Two medications to master • Why these two? Who says? • Low-dose lithium (blood level <0.8) : lithium primer • lamotrigine

– Non-medication component • Who will do basics in house? (diet, exercise, substance use) • Patient education • Regular 7-8 hour sleep in darkness

lithium Eskalith

valproate/divalproex Depakote

carbamazepine Tegretol, Carbatrol

oxcarbazepine Trileptal

lamotrigine Lamictal

olanzapine Zyprexa

quetiapine Seroquel

omega-3 fatty acids fish oil

aripiprazole Abilify

risperidone Risperdal

ziprasidone Geodon

“Mood Stabilizers”

lithium Eskalith

valproate/divalproex Depakote

carbamazepine Tegretol, Carbatrol

oxcarbazepine Trileptal

lamotrigine Lamictal

olanzapine Zyprexa

quetiapine Seroquel

omega-3 fatty acids fish oil

aripiprazole Abilify

risperidone Risperdal

ziprasidone Geodon

“Mood Stabilizers”

BP Depression : “monotherapy” guidelines lithium lamotrigine quetiapine

2003 British Ass’n Psychopharmacology (valproate/

antipsychotic)

2004 Australian/NZ College of Psychiatry - 2005 American Psychiatric Ass’n 2005 TMAP (Texas) 2006 NICE (European) (valproate) (antipsychotic)

2009 CANMAT (Canada) TMAP: Texas Medical Algorithm Project NICE: National Institute for Health and Clinical Excellence CANMAT: Canadian Network for Mood/Anxiety Treatment Adapted from Malhi et al.

Bipolar Disorders, 2009 June

lithium Eskalith

valproate/divalproex Depakote

carbamazepine Tegretol, Carbatrol

oxcarbazepine Trileptal

lamotrigine Lamictal

olanzapine Zyprexa

quetiapine Seroquel

omega-3 fatty acids fish oil

aripiprazole Abilify

risperidone Risperdal

ziprasidone Geodon

pregnancy breast-feeding

Ms. B., 40 y.o.

Depression; irritable, mild/moderate agitation - no euphoria; DIGFAST (middle insomnia)

- family Hx: father suicide - 1st episode age 19, relationship breakup; >5 - post-partum onset; wax/wane over last year - 3 previous antidepressants; 1 loss of response Thyroid status “normal” Current rx: citalopram 30 mg daily

Ms. B.

“Unipolar or bipolar?”

Depression; irritable, mild/moderate agitation - no euphoria; DIGFAST (middle insomnia)

- family Hx: father suicide - 1st episode age 19, relationship breakup; >5 - post-partum onset; wax/wane over last year - 3 previous antidepressants; 1 loss of response Thyroid status “normal” Current rx: citalopram 30 mg daily

Ms. B.

“Unipolar”: augmentation options?

Depression; irritable, mild/moderate agitation - no euphoria; DIGFAST (middle insomnia)

- family Hx: father suicide - 1st episode age 19, relationship breakup; >5 - post-partum onset, wax/wane over last year - 3 previous antidepressants; 1 loss of response Thyroid status “normal” Current rx: citalopram 30 mg daily

Lithium augmentation

Bschor et al, Pharmacopsychiatry, 2003

Ms. B.

lithium: pro’s and con’s?

Depression; irritable, mild/moderate agitation - no euphoria; DIGFAST (middle insomnia)

- family Hx: father suicide - 1st episode age 19, relationship breakup; >5 - post-partum onset, wax/wane over last year - 3 previous antidepressants; 1 loss of response Thyroid status “normal”

Pro’s Con’s

lithium <0.8

Best known Fast “Neurotrophic” Low incidence of SE’s Cheap

1-in-15 “blah’s”: stop Renal risk: 10-year, high dose Toxicity: antihypertensives, NSAIDS Thyroid: monitor closely Tremor: lower dose Nausea: try XR

Ms. B.

lamotrigine

Depression; irritable, mild/moderate agitation - no euphoria; DIGFAST (middle insomnia)

- family Hx: father suicide - 1st episode age 19, relationship breakup; >5 - post-partum onset, wax/wane over last year - 3 previous antidepressants; 1 loss of response Thyroid status “normal” Current rx: citalopram 30 mg daily

Ms. B.

lamotrigine: pro’s and con’s?

Depression; irritable, mild/moderate agitation - no euphoria; DIGFAST (middle insomnia)

- family Hx: father suicide - 1st episode age 19, relationship breakup; >5 - post-partum onset, wax/wane over last year - 3 previous antidepressants; 1 loss of response Thyroid status “normal”

Lamotrigine: Rash Onset

0 14 28 42 56 70 84 98 112 126 140 154 168 182 196 210 224 238 252 266 280 294 308 322 336 350 364 378 392 Rash Onset Time in Days

Messenheimer J, et al. Drug Safety 1998;18(4):281-96

6 weeks

Lamotrigine: Dosing Week Standard

Dose

1 and 2 25

3 and 4 50

5 100

6 200

7

8

Lamotrigine: Dosing Week Standard

Dose Cautious Option

1 and 2 25 25

3 and 4 50 50

5 100 75

6 200 100

7 150

8 200

olanzapine/fluoxetine combination v. lamotrigine

Brown EB et al, J Clin Psychiatry, 2006

Pro’s Con’s

lithium <0.8

Best known Fast “Neurotrophic” Low incidence of SE’s Cheap

1-in-15 “blah’s”: stop Renal risk: 10-year, high dose Toxicity: antihypertensives, NSAIDS Thyroid: monitor closely Tremor: lower dose (B-blocker) Nausea: try XR

lamotrigine

No long term risks No weight gain No labs No side effects

1-in-20 worsening Moderately complex titration Benign rash risk 1-in-10 SJS/TEN 1-in-1,000 (1-in-3,000?) (hair loss)

Treatment

– Two medications to master • Why these two? Who says? • Low-dose lithium (blood level <0.8) : lithium primer • lamotrigine

– Non-medication component • Therapist, up-trained CMA, health coach; groups • Substance abuse; regular physical activity; weight control diet • Patient education • Regular sleep (and darkness: Dark Therapy, blue light, dawn simulators,

amber lenses)

1. Screen before antidepressants

2. lamotrigine at least; lithium?

3. Non-medication component 1. Regular sleep 2. Psychoeducation (PsychEducation.org)

Bipolar Disorder in OB-GYN