BIPOLAR DISORDER IN PRIMARY CARE

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1 E-Resource January, 2014 BIPOLAR DISORDER IN PRIMARY CARE Mood Disorder Questionnaire Common Comorbidities Evaluation of Patients with BPD Management of BPD in Primary Care Patient resource Patients with bipolar disorder (BPD) frequently visit primary care to seek treatment, however, BPD is commonly misdiagnosed or underdiagnosed in primary care settings. Notably, misdiagnosis is often prompted by patient presentation, as patients with BPD tend to present with depressive symptoms and are not likely to discuss other symptoms, including mania. The following resource provides helpful information for detecting and managing BPD within the primary care setting BPD is characterized by episodes of major depression, mania, hypomania, or mixed states. Patients with BPD may display a wide range of symptoms, which can be classified into 4 domains: Manic mood and behavior: Euphoria, grandiosity, pressured speech, impulsivity, excessive libido, recklessness, social intrusiveness, diminished need for sleep Dysphoric or negative mood and behavior: depression, anxiety, irritability, hostility, violence or suicide Psychotic symptoms: delusions, hallucinations Cognitive symptoms: racing thoughts, distractibility, disorientation, inattentiveness Patients with BPD may exhibit physical symptoms of their disease including alcohol-related problems, sexually transmitted diseases, or infections related to drug use. Patients with BPD also tend to have troubling social histories including relationship or martial problems, financial trouble, erratic work history, or persistent legal trouble. If you suspect a patient may have BPD, the Mood Disorder Questionnaire (MDQ) is a screening tool which may be used for further evaluation (see pages 2-3). Common Comorbidities Nearly all patients with BPD report having at least one co-occurring psychiatric disorder in their lifetime and most report having 3 or more. Common psychiatric disorders among BPD patients include: Anxiety disorders Substance use disorders Conduct disorders Adult antisocial behaviors Common medical comorbidities among BPD patients include: Migraine Thyroid disease Overweight and obesity Diabetes Cardiovascular disease and hypertension Chronic obstructive pulmonary disease and asthma Human immunodeficiency virus Hepatitis C Evaluation of Patients with BPD Because patients with BPD may present in primary care with a variety of symptoms, differential diagnosis should include psychiatric conditions such as schizophrenia, schizoaffective disorder, post-traumatic stress disorder, substance abuse and personality disorders, as well as medical conditions including thyroid disease, stroke, partial complex seizures, lupus, HIV, and tertiary syphilis. It is important for primary care providers to conduct a thorough medical and psychiatric history along with a physical examination to adequately assess the patient s current state. The patient evaluation should include: A physical examination with a focus on the neurological and endocrine systems Observation for signs of alcohol or substance abuse Laboratory testing, including: thyroid stimulating hormone (TSH), complete blood count, blood chemistries, and urine toxicology test for detection of substance abuse Other testing such as brain imaging or electroencephalogram (EEG) based on findings in the history, examination and laboratory studies Patients with BPD are most likely to seek care during depressive episodes and many cases are misinterpreted as signs of a depressive disorder. In cases where BPD is suspected, it is important to assess whether a family history of mood disorders exists (the MDQ may be used as a screening tool). If screening suggests a family history of mood disorders, a diagnosis of BPD should be considered. A suicide assessment should be performed on patients with suspected BPD due to the high risk of suicide attempt among these patients. Between 25-50% of patients with BPD attempt suicide and approximately 15% die by suicide. Suicide risk is highest during depressive and dysphoric-irritable mood states and less common during periods of mania and hypomania. Management of BPD in Primary Care While treatment for BPD is best done in a psychiatric setting, treatment of medical conditions associated with BPD likely occurs in primary care. Patients with BPD are at a higher risk for medical comorbidity and early death, especially due to cardiovascular mortality. Medications used to treat BPD may contribute to the development of medical conditions. Specifically, taking atypical antipsychotics may lead to weight gain and changes in metabolism, which cause diabetes and high cholesterol. Further, the use of antipsychotics can lead to the development of tardive dyskinesia, a condition which causes involuntary muscle movements, particularly around the mouth. Patients taking antipsychotics should be thoroughly evaluated in the primary care setting to determine if any medical conditions related to BPD exist. For further information and guidance regarding Bipolar disorder, please contact the Virtual Guidance Service at About the Virtual Guidance Program JPS Health Network is proud to offer a new behavioral health clinical guidance resource to all primary care providers in our region. The JPS Behavioral Health Virtual Resource service offers: Telephone consultation with a behavioral health clinical team member Referral to community resources benefiting behavioral health patients Online reference library of behavioral health education materials Educational opportunities to increase provider understanding and comfort level in treating behavioral health conditions. Call or visit for more information and to access a free virtual consultation for your patient

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4 The Following Pages are Patient Education Material

5 Bipolar Disorder (JPS Health Conditions and Procedures) The Basics Written by the doctors and editors at UpToDate What is bipolar disorder? Bipolar disorder (sometimes called manic depression ) is a brain disorder that causes extreme changes in mood and behavior (figure 1). Bipolar disorder can run in families. What are the symptoms of bipolar disorder? People with bipolar disorder can feel much happier or much sadder than normal. If you have bipolar disorder, you might feel very happy for many days and then feel very sad. When your mood is very happy, you can also: Get angry quickly Be more active than normal Feel like you have special powers Feel like you don t need sleep Make poor choices without thinking Start lots of things and not finish them Other times, your mood might be very sad for most of the day, every day. When your mood is very sad, you can also: Lose or gain a lot of weight Have trouble falling asleep or sleep too much Feel very tired Not enjoy things Feel bad about yourself Think about death or hurting yourself People with bipolar disorder might have trouble at work or school. They might not get along well with their family and friends. Is there a test for bipolar disorder? No. There is no test. But your doctor or nurse should be able to tell if you have it by talking with you and your family. He or she will ask about your mood and what you have been feeling and doing. Your doctor or nurse might also do an exam and order blood tests to look for other problems.

6 How is bipolar disorder treated? Bipolar disorder is treated with medicine. Talk therapy can also help. Medicines sometimes take a while to start working. Plus, it sometimes takes a few tries to find the right medicine or combination of medicines. You and your doctor will work together to find the medicine that works best for you. All of the medicines for bipolar disorder affect the brain. They can: Keep your mood even and prevent big mood changes Calm your mind Make your sadness go away Medicines sometimes cause side effects. You might also need to stay in the hospital for a short time. When a bipolar disorder mood episode starts, you might be at risk of hurting yourself or others. You might hear voices that other people do not hear. You might believe things that are not true. But if you are at the hospital, the doctors can treat these symptoms and keep you safe. Some people whose bipolar disorder makes them feel very sad might need shock treatment to get better. Doctors call this treatment ECT. During ECT, doctors shock a person s brain in a safe way. Is there anything I can do to prevent big mood changes in the future? Yes. After your symptoms have gone away, you will probably: Keep taking medicine every day to help keep your mood and behavior even Go to talk therapy to help you get along better with family and friends What if I want to get pregnant? If you want to get pregnant, you will need to talk with your doctor. Some medicines for bipolar disorder are OK to take if you are pregnant. Others are not. You might need to slowly reduce or change your medicine. What will my life be like? Many people with bipolar disorder are able to live normal lives, but they might: Have times of feeling very happy or very sad again in the future Take drugs or drink alcohol. If this happens, talk to your doctor. Try to hurt themselves. If you ever feel like hurting yourself, call your doctor, go to the hospital, or dial

Bipolar Disorder. When people with bipolar disorder feel very happy and "up," they are also much more active than usual. This is called mania.

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