35-year-old woman with Hx of BPII Dx; currently separated from husband; has 1 child

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1 Stephen M. Strakowski, MD Chart Review: Bipolar Disorder PATIENT INFO 35 Age: Female Sex: 35-year-old woman with Hx of BPII Dx; currently separated from husband; has 1 child Background: SI and hospitalization (left AMA); no psychosis, mania, or postpartum depression; no substance abuse Patient History: Mother, father, and paternal aunt treated for depression; Family History: maternal grandmother: paranoid schizophrenia; paternal grandfather, both paternal uncles, and father all alcoholics Presenting Complaint: Mood depressed, irritable, somnolence Reports talking fast despite normal rate Anxiety severe with panic; FOI/LOA Poor concentration/focus AMA = against medical advice; BPII = bipolar disorder II; FOI/LOA = flight of ideas/loosening of associations; SI = suicidal ideation; WNL = within normal limits Best Practices List three best practices agreed to by the group in your chart review session: 1. Establish history and patterns of mood changes, life events and medication response. Need an ongoing and careful assessment. Need to do mood charting. 2. Need to do systematic medication challenges and document mood changes. Monotherapy should be the goal although rarely achieved. 3. Develop a comprehensive treatment program including psychosocial interventions that considers adherence factors, response to treatment and suicide risk

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3 Bipolar Disorder Chart Review Stephen M. Strakowski, MD University of Cincinnati College of Medicine

4 Stephen M. Strakowski, MD Disclosures Research/Grants (UC Academic Health Center): AstraZeneca Pharmaceuticals LP; Bristol-Myers Squibb Company; Eli Lilly and Company; Forest Laboratories, Inc.; Janssen, LP; Johnson & Johnson Pharmaceutical Research & Development, LLC; Martek Biosciences; National Alliance for Research on Schizophrenia and Depression; National Institute on Alcohol Abuse and Alcoholism; National Institute on Drug Abuse; Nutrition 21; Pfizer Inc.; Repligen Corporation; Shire Pharmaceuticals; Somerset Pharmaceuticals, Inc.; Thrasher Foundation Speakers Bureau: France foundation Consultant: Pfizer Inc. Stockholder: None Other Financial Interest: None Advisory Board: None

5 Learning Objective Identify 3 types of interventions that may be appropriate for a patient with bipolar disorder

6 Case Example: KD 35-year-old woman with Hx of BPII Dx Currently separated from husband; has 1 child Chief complaint: Mood depressed, irritable, somnolence Reports talking fast despite normal rate Anxiety severe with panic; FOI/LOA Poor concentration/focus BPII = bipolar disorder II; FOI/LOA = flight of ideas/loosening of associations

7 Case Example KD Patient/Family History Patient Hx: SI and hospitalization (left AMA) No psychosis, mania, or postpartum depression No substance abuse Family Hx: Mother, father, and paternal aunt treated for depression Maternal grandmother: paranoid schizophrenia Paternal grandfather, both paternal uncles, and father all alcoholics AMA = against medical advice

8 Case Example KD Treatment History Prior treatment: Lamotrigine, aripiprazole, quetiapine, fluoxetine, paroxetine, citalopram, escitalopram, venlafaxine XR, duloxetine, sertraline, bupropion XL, buspirone, lorazepam, zolpidem Since 9/2008: carbamazepine 400mg bid Labs all WNL Had been stable until recently Poor response to increased carbamazepine Tried ziprasidone, then olanzapine Complained of side effects WNL = within normal limits

9 Case Example: Questions What else do you want to know? What are the critical pieces of information for diagnosis? What are possible treatment interventions?

10 Tolerability of Selected Compounds Drug Weight Gain CNS EPS Derm GI Lithium 0 Divalproex 0 Carbamazepine 0 Lamotrigine 0 Olanzapine Risperidone Ziprasidone Quetiapine 0/ Aripiprazole 0 = none known (placebo rate); = minimal or rare; = moderate or occasional; = severe or common; CNS = central nervous system; Derm = dermatologic; EPS = extrapyramidal symptoms; GI = gastrointestinal Strakowski SM, et al. CNS Drugs 2001;15: Strakowski SM, et al. Exp Op Pharmacother 2003;4:

11 Nonpharmacologic Interventions Several nonpharmacologic interventions may help stabilize patients over time Cognitive-behavioral therapy 1,2,3 Group therapies 1,4 Maintaining a regular schedule/sleep habits Phototherapy Develop strategies for managing stressors 5 Remember to treat comorbidities e.g., substance abuse 1. Colom F, et al. Arch Gen Psychiatry 2003;60: Lam DH, et al. Arch Gen Psychiatry 2003;60: Lam DH, et al. Am J Psychiatry 2005;162: Rea MM, et al. J Consult Clin Psychol 2003;71: Miklowitz DJ, et al. Psychiatry Res 2005;136:

12 Mood Charting April MANIC DEPRESSED Severe Moderate Mild None Mild Moderate Severe X X X X X X X X X X X X X X X X X X X X X X X X X Antidepressant

13 Lifelong Care for Bipolar Disorder Multi-Faceted for Best Outcome Identify tolerable, effective treatment Unlikely all symptoms will go away Look for patterns of improvement on mood chart Aim for monotherapy (rarely achieved) Change one thing at a time Develop long-term strategic plans APA. Practice Guideline for BP Disorder Second Edition, Accessed July 2009.

14 Lifelong Care for Bipolar Disorder Multi-Faceted for Best Outcome Integrate CBT or other accepted therapy DBSA and other support group Address lifestyle changes and support Eliminate bad stuff DBSA = Depression and Bipolar Support Alliance APA. Practice Guideline for BP Disorder Second Edition, Accessed July 2009.

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16 Bipolar Disorder Stephen M. Strakowski, MD American Psychiatric Association. Practice Guideline for the Treatment of Patients With Bipolar Disorder Second Edition, Available at: Accessed July Colom F, Vieta E, Martinez-Aran A, et al. A randomized trial on the efficacy of group psychoeducation in the prophylaxis of recurrences in bipolar patients whose disease is in remission. Arch Gen Psychiatry 2003;60: Lam DH, Watkins ER, Hayward P, et al. A randomized controlled study of cognitive therapy for relapse prevention for bipolar affective disorder: outcome of the first year. Arch Gen Psychiatry 2003;60: Lam DH, Hayward P, Watkins ER, Wright K, Sham P. Relapse prevention in patients with bipolar disorder: cognitive therapy outcome after 2 years. Am J Psychiatry 2005;162: Miklowitz DJ, Wisniewski SR, Miyahara S, Otto MW, Sachs GS. Perceived criticism from family members as a predictor of the oneyear course of bipolar disorder. Psychiatry Res 2005;136: Rea MM, Tompson MC, Miklowitz DJ, Goldstein MJ, Hwang S, Mintz J. Family-focused treatment versus individual treatment for bipolar disorder: results of a randomized clinical trial. J Consult Clin Psychol 2003;71: Strakowski SM, Del Bello MP, Adler CM, Keck PE Jr. Atypical antipsychotics in the treatment of bipolar disorder. Exp Op Pharmacother 2003;4: Strakowski SM, Del Bello MP, Adler CM. Comparative efficacy and tolerability of drug treatments for bipolar disorder. CNS Drugs 2001;15: