SOAP. – Bipolar Disorder – SỔ TAY LÂM SÀNG

Bipolar Disorder

Alyson Wolz

Definition

A.Bipolar disorder, commonly called manic-depressive disorder, is a psychiatric disorder that causes changes in moods, thoughts, and behaviors. These changes may range from mania (excessive energy, euphoria, racing thoughts, decreased need for sleep, grandiosity, pressured speech, and impulsive behavior) to depression (low energy, sadness, diminished interest and pleasure in most activities, recurrent thoughts of death, changes in sleep patterns, cognitive impairment, and difficulty carrying out daily activities.

B.There are four types of bipolar disorder. Bipolar I disorder is diagnosed when the individual experiences a manic episode, which may have been preceded or followed by a hypomanic or depressive episode. Individuals with Bipolar II disorder have a pattern of depressive episodes and hypomanic episodes (no mania). Often symptoms of depression and hypomania, especially agitation, irritability, and verbal impulsivity are displayed in the same episode (mixed). Cyclothymic disorder is a chronic pattern of hypomanic and depressive symptoms that do not meet the full criteria for hypomania or depressive episodes. Symptoms occur for at least 2 years (1 year in children and adolescents). The unspecified bipolar and related disorder category applies to situations in which there are symptoms that are characteristic of bipolar disorder, but they do not meet the full criteria. There may be insufficient information to make a diagnosis, or underlying medical conditions or substance use contributing to the condition. Specific criteria for bipolar disorder as published by the American Psychiatric Association (APA), Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (2013) are available at the National Institute for Mental Health website: www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml.

Incidence

A.5.7 million or 2.6% of adults ages 18 or older in the United States.

B.Median age of onset is 25, although can range from childhood to late onset (50s).

C.Bipolar disorders occurs in all races and socioeconomic groups.

D.Men may present with symptoms of mania earlier than women. Women are more likely to present with symptoms of depression and experience more rapid cycling.

E.Bipolar disorder is the sixth leading cause of disability in the world.

F.One in five individuals diagnosed with bipolar disorder will die by suicide.

Predisposing Factors

A.A family history of bipolar disorder or schizophrenia.

B.Periods of high stress.

C.Drug or alcohol abuse.

D.Major life changes such as the death of a loved one or a traumatic experience.

Common Complaints

A.Individuals most frequently seek treatment for depressive episodes.

B.Poor work performance, unfinished tasks.

C.Mood swings, irritability, or anger episodes.

D.Social problems.

E.Sleep disturbance.

Signs and Symptoms

A.Mania:

1.Symptoms lasting at least 1 week.

2.Inflated self-esteem, grandiosity.

3.Decreased need for sleep, talkative, racing thoughts, distractibility.

4.Increase in goal-directed activity.

5.Impulsive behavior (buying sprees, sexual indiscretions, poor business decisions).

6.Symptoms cause marked impairment in functioning and may require hospitalization.

B.Hypomania:

1.Symptoms lasting at least 4 days.

2.Symptoms same as mania, but are not severe enough to cause marked impairment.

3.Frequently displays irritability and agitation.

C.Depression:

1.Symptoms lasting for at least 2 weeks.

2.Symptoms are similar to major depressive disorder: depressed mood most of the day, diminished interest in pleasure, changes in weight, sleep disturbance, restlessness or low energy, fatigue, feelings of worthlessness, guilt, and burdensomeness, cognitive changes, thoughts of death.

D.Impulse control:

1.Patient may present as extremely happy and sociable.

2.May have rapid mood changes, such as irritability or aggression when wishes are denied, especially if using substances.

E.Suicidal or homicidal thoughts or acts. Any statements made by the patient, such as Life isn’t worth living, I wish I were dead, I don’t deserve to be alive, I can’t deal with this, should be taken seriously. Refer the patient for immediate mental health assessment and treatment.

Subjective Data

A.Review the onset, duration, and course of presenting symptoms.

B.Review any previous history of depression, mania, or mood disorders.

C.Determine how the previous mood disorder was treated, if applicable.

D.Evaluate the patient’s suicide potential. Ask: Have you ever thought of hurting yourself or others? Does the patient have a current suicide plan or vague ideas of suicide? Has the patient had any previous history of suicide attempts? If so, evaluate how life-threatening they were.

E.Review the patient’s medical history.

F.Review the patient’s drug history for prescription, over-the-counter (OTC), and recreational/illicit drug use (how much, how long, how often), and review his or her history of alcohol consumption (how much, how long, how often).

G.Assess patient’s compliance with prescribed medications.

H.Review the patient’s history for recent major life changes such as pregnancy, death, divorce, or any loss that may be normal throughout the stages of life. The patient’s perception of the loss is what is important.

I.Review dietary intake since the symptoms have begun.

J.Establish usual weight, review weight gain/loss, and in what time span.

K.Review the patient’s activities of daily living (ADLs). Does the patient get up and dress daily, perform daily hygiene, put on makeup?

L.Review how many hours of sleep and quality of sleep per day.

M.Review the disruption of usual activities: return to work, return to school, exercise. Has the patient been engaging in activities outside their norm?

N.Assess mood patterns, rate of cycling, seasonal changes.

O.Review occupational/home exposure to neurodegenerative products.

P.Review any exposures to infectious diseases, including Lyme disease. Does anyone else such as family, friends, or coworkers have similar symptoms?

Q.If female, review for symptoms of menopause (sleep disturbances, irregular menses/amenorrhea, hot flashes, vaginal dryness, dyspareunia).

Physical Examination

A.Check, pulse, respirations, blood pressure, and weight.

B.Inspect:

1.Observe overall appearance; note grooming, tone of voice, eye contact, conduct of patient during communication, and breath (smell of alcohol).

2.Complete neurologic examination with screening tool of choice.

3.Complete dermal examination for signs of substance use (refer to Substance Use Disorders section of this chapter).

C.Palpate:

1.Palpate the neck and thyroid; note the goiter.

2.Palpate the axilla and groin for lymphadenopathy (infectious etiology).

3.Check the joints for swelling and arthritis and range of motion (ROM; rule out musculoskeletal cause).

D.Auscultate the heart, lungs, and abdomen (as applies to physical complaints).

E.Complete Mental Status Exam (MSE), including appearance, affect/mood, thought content, perception, suicide/self-destruction, homicide/aggression, judgment/insight, and cognition.

Diagnostic Tests

A.Complete blood count (CBC) to rule out iron-deficiency anemia.

B.Urine/serum drug screen.

C.Thyroid studies to rule out other organic problems.

D.Comprehensive metabolic panel (CMP).

E.Erythrocyte sedimentation rate (ESR).

F.Liver and lipid panel.

G.Refer for psychological testing to confirm diagnosis, to rule out other mental health disorders, and to assess for social/emotional adjustment and presence of learning disabilities.

H.ECG.

I.EEG may be considered.

J.CT scan or MRI may be considered to rule out organic diagnoses.

Differential Diagnoses

A.Bipolar disorder.

B.Substance-induced mood disorder, including caffeine, alcohol/illicit drugs.

C.Head trauma.

D.Hyperthyroidism/hypothyroidism.

E.Lead poisoning.

F.Other behavioral/psychological disorders (pervasive developmental delay, oppositional defiant disorder, seasonal affective disorder (SAD), anxiety disorder, schizoaffective disorder, schizophrenia, and personality disorder).

G.Posttraumatic stress disorder (PTSD).

H.Attention deficit hyperactivity disorder (ADHD)/learning disorders (in children).

I.Seizure disorder, nonconvulsive.

J.Medical conditions (menopause, neurosyphilis, multiple sclerosis, Lyme disease).

K.Adverse reactions to medications (theophylline, prednisone, albuterol, Levaquin, and antidepressant medications (may induce mania).

Plan

A.General interventions:

1.Keep the patient safe from self-harm.

2.Treat physical/laboratory findings. Recommend dietary change, iron supplements, hormone replacement therapy per findings (see related chapters).

B.Patient teaching:

1.Encourage the patient to take medications as prescribed. Educate the patient that some medications may take time to get into the system to work and time should be allowed to see the effects of the medication. Review side effects.

2.Encourage the patient to express feelings or worsening of symptoms if this occurs prior to next appointment. Have the patient make a client contract with you that he or she will not hurt himself or others and if he or she begins having these thoughts, the patient will contact you or go to the nearest emergency room.

3.Encourage exercise on a daily basis for 20 to 30 minutes to increase energy and enhance a feeling of well-being.

4.Encourage the patient to get at least 7 to 8 hours of sleep each night. If sleep is a problem, address this issue with the client.

5.Avoid caffeine at night and/or watching TV late at night.

6.Encourage the patient to seek counseling with a professional counselor. Refer to appropriate site (psychologist, psychiatrist, group therapy, etc.). Offer local resources to the patient.

7.Advise patient to participate in activities to enhance interpersonal relationships and build self-esteem. Include family and friends in recommended therapies and advise them to encourage the patient to participate in activities to enhance self-esteem.

8.Once the patient is feeling better, encourage continued use of medication, activities, and resources.

Bipolar disorder is a chronic condition requiring longterm, continuous treatment. Untreated episodes of mania and depression may become more severe and more difficult to treat over time.

C.Pharmaceutical therapy.

Medication choice depends on the current episode: mania/depression.

1.Mood stabilizers:

a.Divalproex sodium (Depakote, Depakote ER):

i.Indicated for mania.

ii.Initial dose of 25 mg/kg/d mg daily in divided doses.

iii.Increase as quickly as possible to achieve target plasma concentrations of 50 to 125 mcg/mL.

iv.Maximum concentration achieved within 14 days.

v.Maximum recommended dose is 60 mg/kg/d.

vi.Drug–drug interactions: May increase concentrations of clonazepam, diazepam, lamotrigine, and carbamazepine. Aspirin increases Depakote blood levels.

vii.Labs: Check valproic acid level, liver function test (LFT), CBC after 1 week, then at 1 to 2 months, then every 6 to 12 months thereafter.

viii.Side effects: Dizziness, sedation, nausea, tremor, thrombocytopenia, elevated liver enzymes, polycystic ovarian syndrome, hepatotoxicity (rare).

ix.Monitoring: Serum drug levels during treatment initiation. Monitor weight and menstrual history every 3 months for the first year, then annually.

b.Carbamazepine ER (Equetro):

i.Indicated for mania and mixed episode.

ii.Initial dose of 200 mg BID.

iii.Adjust dose in 200 mg increments.

iv.Capsules may be taken whole or opened and sprinkled on food.

v.Do not use with monoamine inhibitors oxidases (MOAIs) or within 14 days of using an MOAI.

vi.Side effects: Dizziness, somnolence, dry mouth, constipation, aplastic anemia, agranulocytosis, rash, toxic epidermal necrolysis (TEN), Stevens–Johnson Syndrome (SJS; patients of Asian ancestry have a 10-fold greater risk of TEN/SJS).

vii.Monitoring: Serum drug levels during treatment initiation and as clinically indicated. CBC, LFT, electrolytes, blood urea nitrogen (BUN), creatinine monthly for 3 months, then annually.

c.Lithium:

i.Indicated for mania and maintenance.

ii.Lithium workup prior to initiating the medication: ECG, BUN/creatinine, urinalysis, CMP, thyroid-stimulating hormone (TSH).

iii.Initial dose of 300mg BID.

iv.Lithium levels drawn 2x per week with dose adjustments in 300 mg increments until target serum levels are reached: Target serum levels 0.6 to 1.2 mEq/L. Levels should be drawn 12 hours after last dose.

v.Lithium toxicity: Nausea, vomiting, diarrhea, muscular weakness, lack of coordination, giddiness, and large output of dilute urine. May involve multiple organs and organ systems.

vi.Monitoring: Serum drug levels every 3 to 6 months once stable. Electrolytes, BUN, creatinine every 3 to 6 months to exclude renal impairment. TSH, calcium, and weight after 6 months, then annually.

d.Lamotrigine (Lamictal):

i.Indicated for maintenance therapy.

ii.Must titrate slowly due to risk of rash/SJS.

iii.Target dose of 200 mg to 400 mg.

iv.Titration dose adjustments required if patient is on Depakote (slower titration) or carbamazepine (faster titration).

v.Side effects: Nausea, insomnia, somnolence, rash, leg cramps, aphasia, and Stevens–Johnson Syndrome (SJS).

2.Atypical antipsychotics:

Potential side effects for all atypical antipsychotics

•Extrapyramidal and/or withdrawal symptoms in neonates with third trimester exposure.

•Lower seizure threshold.

•Leukopenia, neutropenia, and agranulocytosis.

•Metabolic changes including hyperglycemia/diabetes, dyslipidemia, weight gain.

•Orthostatic hypotension.

•Tardive dyskinesia.

•Cognitive and motor impairment.

•Increased risk of stroke in elderly patients with dementia-related psychosis; elderly patients with a history of cerebrovascular accident (CVA) treated with antipsychotic medications are at an increased risk of death.

•Suicidal thinking.

•Neuroleptic malignant syndrome (NMS): High fever, stiff muscles, confusion, sweating, changes in pulse, heart rate, and elevated blood pressure.

•Labs: Monitor body mass index (BMI), waist circumference, HbA1c, fasting plasma glucose, fasting lipid panel at baseline, 3 months, and then annually.

a.Aripiprazole (Abilify):

i.Indicated for mania, mixed episodes, and maintenance.

ii.Initial dose: 15 mg daily (10–15 mg if using in addition to a mood stabilizer). Once daily with or without meals.

iii.Available in tablets, orally disintegrating tablets, oral solution, and injectable 9.75 mg/1.3 mL single-dose vial.

iv.Maximum recommended dose: 30 mg daily.

v.Drug–drug interactions: Known CYP2D6 poor metabolizers, strong CYP2D6 or CYP3A4 inhibitors: ½ dose. Known CYP2D6 poor metabolizers and strong CYP3A4 inhibitors: ¼ dose.

vi.Common side effects: Akathesia (restlessness), weight gain, nausea, constipation, headache, dizziness, stuffy nose.

b.Ziprasidone (Geodon):

i.Indicated as monotherapy for mania and mixed episodes and as an adjunct to lithium or valproate for maintenance.

ii.Initial dose: Mania: 40 mg twice daily, with increase to 60 mg to 80 mg twice daily on day 2 of treatment. Giving oral doses with food increases absorption up to two-fold.

iii.Available in capsules and injectable 20 mg/mL single-dose vial.

iv.Maximum recommended dose: 60 mg to 80 mg twice daily with food.

v.Drug–drug interactions: Do not give with other medications known to cause QT prolongation.

vi.Side effects: QT prolongation. Do not use in patients with recent heart failure, recent heart attack, or arrhythmias. Other more common side effects include akathesia (restlessness), sleepiness, weight gain, nausea, constipation, headache, dizziness, stuffy nose. Less common: Severe cutaneous adverse reactions (SCAR) such as SJS.

c.Risperidone (Risperdal/Risperdal Consta):

i.Indicated as monotherapy for mania and mixed episodes, and as an adjunct to lithium or valproate for maintenance therapy.

ii.Dosing:

•Risperidone: 2 to 3 mg daily with titration in 1 mg increments at intervals of 24 hours or greater. Target dose of 1 to 6 mg daily. Max dosing 6 mg/d. Once or twice daily with or without meals. Available in tablets, orally disintegrating tablets, and oral solution 1 mg/mL.

•Risperdal Consta: 25 mg intramuscularly (IM) q 2 weeks with dose increase in 4-week intervals. Max dosing 37.5 to 50 mg IM q 2 weeks. Oral dose of risperidone should be used along with the first injection of Risperdal Consta, and continued for 3 weeks. Available in dose strengths of 12.5 mg, 25 mg, 37.5 mg, or 50 mg.

iii.Drug–drug interactions: CYP2D6 enzyme inducers (carbamazepine), may need to increase dose up to double the patient’s usual dose. CYP2D6 enzyme inhibitors (paroxetine, fluoxetine), dose of risperidone should be titrated slowly and dose may need to be decreased.

iv.Side effects: Dizziness, drooling, nausea, tiredness, weight gain, akathesia, tremor, blurred vision, QT prolongation, increased prolactin levels. Dose adjustment recommended for patients with severe renal or hepatic impairment. Monitor prolactin levels along with other recommended labs.

d.Asenapine (Saphris): Dissolvable:

i.Indicated as monotherapy for mania and mixed episodes, and as an adjunct to lithium or valproate for maintenance therapy.

ii.Initial dose: 5 to 10 mg sublingually twice daily.

iii.Available in sublingual tablets only.

iv.Maximum recommended dose: 10 mg twice daily.

v.Drug–drug interactions: Antihypertensive drugs: Saphris may cause hypotension. Paroxetine (CYP2D6 substrate and inhibitor): Reduce paroxetine dose by ½ when used in combination with Saphris.

vi.Common side effects: Orthostatic hypotension, syncope, akathesia (restlessness), weight gain, nausea, constipation, headache dizziness, stuffy nose. Contraindicated in patients with severe hepatic impairment.

e.Quetiapine (Seroquel/Seroquel XR):

i.Indicated as monotherapy for bipolar mania, mixed, and depressive episodes, and as an

adjunct to lithium or valproate for maintenance therapy.

ii.Dosing: Mania: 50 mg twice daily. Dose adjustments in increments of 100 mg daily up to total of 400 mg. Further dose adjustments up to 800 mg/d should be in increments of no greater than 200 mg/d. Target dose: 400 to 800 mg daily. Maximum recommended dose: 800 mg/d. Depression: Administer once daily at bedtime. Initial dose of 50 mg at bedtime. Increase to 100 mg on day 2 with further increases of 100 mg daily up to 300 mg/d. Target dose: 300 mg/d. Maximum daily dose: 300 mg

iii.Quetiapine extended release: Bipolar mania/mixed episode: Initial dose of 300 mg daily in evening without food or with light meal. Target dose 400 to 600 mg daily. Max dosing 600 mg daily. Bipolar depression: 50 mg daily in evening without food or with a light meal. Target dose: 300 mg daily. Maximum recommended dose: 300 mg daily.

iv.Drug–drug interactions: Dose should be increased up to five-fold of the original dose when used in combination with a potent CYP3A4 inducer. Titrate dose based on clinical response and tolerability. Dose should be reduced to 1/6 of the original dose when used in combination with a potent CYP3A4 inhibitor. Quetiapine may cause hypotension, thus enhancing the effects of antihypertensive medications.

v.Side effects: Somnolence, dry mouth, dysarthria, increased appetite, weight gain, nausea, constipation, dizziness, stuffy nose, joint pain, QT prolongation, hypotension.

f.Olanzapine (Zyprexa, Zydis):

i.Indicated for mania, mixed episodes, and maintenance monotherapy.

ii.Initial dose: 10 to 15 mg once daily with or without meals, with dose adjustments of 5 mg daily.

iii.Available in tablets, orally disintegrating tablets, and injectable 10 mg/2.1 mL single-dose vial.

iv.Maximum recommended dose: 20 mg daily.

v.Drug–drug interactions: Coadministration with diazepam may potentiate orthostatic hypotension. Known CYP1A2 inducers, such as carbamazepine, increase the clearance of olanzapine. Titrate dose based on clinical response and tolerability. When used in combination with CYP1A2 inhibitors, such as fluvoxamine, lower doses of olanzapine should be considered.

vi.Side effects: Postural hypotension, akathesia (restlessness), increased appetite, weight gain, somnolence, nausea, constipation, headache, dizziness, stuffy nose, and tremors.

g.Olanzapine/fluoxetine combination (Symbyax):

i.Indicated for bipolar depression.

ii.Initial dose: 6 mg/25 mg capsule daily in the evening (mg equivalent olanzapine/mg equivalent fluoxetine). Dose adjustments as needed and tolerated. Target dose: Within the approved dosing range of 6/25, 6/50, 12/25, 12/50 mg.

iii.Maximum recommended dose: 18 mg/75 mg daily in evening.

iv.Drug–drug interactions: Same as with olanzapine and fluoxetine individually.

v.Common side effects: Akathesia (restlessness), increased appetite, fatigue, somnolence, peripheral edema, blurred vision, weight gain, nausea, constipation, headache, dizziness, stuffy nose.

h.Chlorpromazine (Thorazine):

i.Indicated for mania/mixed episode.

ii.Initial dose: 25 mg orally TID with gradual increase until effective dose is reached. Target dose: 400 to 500 mg daily in divided doses.

iii.Available in tablets, spansule/sustained release, single and multidose vials for IM injection, and suppositories.

iv.Maximum recommended dose: 1,000 mg daily

v.Drug–drug interactions: Multiple drug–drug interactions, alpha blockers, anticholinergic/antispasmodic drugs. Avoid use with other medications that may cause QT prolongation or respiratory depression.

vi.Side effects: Drowsiness, postural hypotension, akathesia (restlessness), dystonia, tremor, weight gain, nausea, constipation, headache, dizziness, stuffy nose, QT prolongation.

3.Antidepressants:

a.Use of traditional antidepressants to treat bipolar depression is controversial and not approved by the Food and Drug Administration (FDA).

b.Using antidepressants alone to treat bipolar depression is not recommended due to the potential to cause hypomania, mania, and rapid cycling.

c.Do not prescribe an antidepressant during manic or mixed episodes.

4.Electroconvulsive therapy (ECT):

a.Short-term treatment for severe manic or depressive episodes, especially when suicidal or psychotic symptoms are present, or when medication intervention is ineffective or not well tolerated.

b.ECT is among the safest treatments for severe mood disorders and is effective in up to 75% of patients.

Follow-Up

A.Initially, monitor patients closely to assess for response to treatment, need for medication dose adjustment, side effects, and changes in level of functioning.

B.Monitor for emergence of suicidal thoughts, psychosis, mania, or depression.

C.As appropriate, order lab work to monitor serum blood levels of medications and assess for potential side effects, such as metabolic changes, elevated liver enzymes, decreased kidney functioning, cardiac changes, and blood dyscrasias.

D.After initial stabilization, follow-up appointments should be made every 1 to 3 months.

E.Patient teaching related to importance of self-care and medication compliance.

Consultation/Referral

A.If patient is experiencing suicidal/homicidal ideations, refer immediately to the nearest emergency room to be evaluated by a mental health professional for possible emergency admission.

B.Consult with the psychiatric provider to help coordinate care.

C.Refer the patient for individual and/or family therapy if indicated.

Individual Considerations

A.Pregnancy:

1.Some of the medications used to treat bipolar disorder can potentially lower the effectiveness of hormone contraception. Women should be counseled on the use of additional methods of pregnancy prevention.

2.Medications such as mood stabilizers cause an increased risk of birth defects in the first trimester. Women of childbearing age should be counseled on planned pregnancy to allow for medication adjustment and initiation of supportive therapy/close monitoring.

3.Stopping bipolar medications during pregnancy puts a woman at high risk of relapse during the pregnancy and development of postpartum depression. Some bipolar medications pass through the breast milk. Risk versus benefits of medication use during pregnancy and breastfeeding should be discussed with patient and significant other, if appropriate. Refer to psychiatric specialist for consultation.

B.Partners/family:

1.Provide educational materials and information on local support resources to partners and family members. The National Alliance on Mental Illness provides family support groups and online resources in many rural and urban areas. Information may be accessed at www.nami.org.