Karen S. Blackman, M.D., Amy M. Romain, LMSW, ACSW Identifying and Initiating Treatment for Bipolar Disorder in the Family Medicine Office Karen S. Blackman, M.D., Amy M. Romain, LMSW, ACSW MSU/Sparrow Family Medicine Residency 33rd Forum for Behavioral Science in Family Medicine September 28, 2012 This session is part of the clinical track. Our focus today is to teach an approach to identifying and treating bipolar disorder in a family medicine office. Though this is not a “how to teach” session, the we do use these materials when teaching our family medicine residents.

Sparrow/MSU FMRP Behavioral. Science Team 2012 Commercial Interests Karen Blackman, MD Nothing to disclose Amy Romain, LMSW, ACSW Sparrow/MSU FMRP Behavioral. Science Team 2012

Sparrow/MSU FMRP Behavioral. Science Team 2012 Objectives Diagnose Bipolar Disorder using Self-report Tool for Recognizing Mania (SToRM) Apply the PhASE approach to treating Bipolar Disorder Manage 3 medications for treating Bipolar Disorder in the depressed phase Use psycho-education and self-management techniques for bipolar depression APPROACH! Sparrow/MSU FMRP Behavioral. Science Team 2012

Sparrow/MSU FMRP Behavioral. Science Team 2012 Agenda Diagnosing Bipolar Disorder aided by the SToRM Brief overview of PhASE approach to Bipolar Disorder treatment 3 medications for treating bipolar depression Psychotherapy and self-management strategies for Bipolar Disorder Practice Cases Discussion Sparrow/MSU FMRP Behavioral. Science Team 2012

Sparrow/MSU FMRP Behavioral. Science Team 2012 Handouts SToRM: Self-report Tool for Recognizing Mania (scoring on the back) PhASEs of Bipolar Disorder chart Bipolar Medication Charts (2-sided) Medications for the Phases of Bipolar Disorder Atypical Antipsychotics in Bipolar Disorder Sadie’s and Emily’s StoRMs Mood Disorder Action Plan Sleep Tips and Diary Back to back. We’ll cue you. Sparrow/MSU FMRP Behavioral. Science Team 2012

Sparrow/MSU FMRP Behavioral. Science Team 2012 Importance of Diagnosing and Treating Bipolar Disorder in Primary Care Office Bipolar Disorder symptoms may worsen while waiting for psychiatrist (true of any phase) Individuals with Bipolar Disorder spend most time in depression and this is not responsive to standard treatments Remission as important as with unipolar depression to prevent recurrence Residual anxiety risky Once psychiatrist involved, active role of PCP continues Hirschfield, Robert et al J Clin Psychiatry 64;2, February 2003 According to NIMH, there is a 4% life time prevalence of Bipolar Disorder. Sparrow/MSU FMRP Behavioral. Science Team 2012

“I’d better not treat… What if I’m wrong?” Risks of treating BPD Side effects of the bipolar meds Avoidance of antidepressants which might help if this is unipolar depression Risks of not treating BPD High risk of suicide attempts/completion Recurrence rates high especially if anxiety Lags of 5-10 years seen in national surveys between symptoms and diagnosis – National Depressive and Manic Depressive Association Surveys (1992, 2000) Sparrow/MSU FMRP Behavioral. Science Team 2012

Diagnosing Bipolar Disorder Has patient ever had mania or hypomania? Need this to be considered bipolar Patients may mistake swing to normal mood as manic Bipolar I At least 1 manic episode Often history of depression but not necessary Bipolar II Hypomania and depression HYPOMANIA MAY BE SHORTER AND SOMEWHAT LESS IMPAIRED BUT OTHERWISE VERY MUCH LIKE MANIA Sparrow/MSU FMRP Behavioral. Science Team 2012

“I’m on the fence…Now what?” Create partnership with patient to evaluate and re-evaluate over time Coding/conceptualizing now and in the future DSMIV = Mood Disorder NOS DSMV = Mixed Features Specifier These help us remember we are on the fence and rethink it as new information comes in. Sparrow/MSU FMRP Behavioral. Science Team 2012

Sparrow/MSU FMRP Behavioral. Science Team 2012 Kay Jamieson PhD Psychologist at Johns Hopkins – articulate author and speaker on mood disorders –gives a good example of mania Sparrow/MSU FMRP Behavioral. Science Team 2012

Diagnosing Manic Episode is Key K-SADS Mania Rating Scale Very long and cumbersome Bipolar Spectrum Diagnostic Scale Screening Tool Mood Disorder Questionnaire Screening Tool Young Mania Rating Scale Physician administered Scores intensity of sx for research Manic State Rating Scale Clinician Administered Clinic Self Report Form Looks at progress since last visit MDQ developed and researched by Hirshfeld and others has been somewhat controversial as a screening tool. In psychiatric settings the sensitivity and specificity is fairly high (73/90) but sensitivity is lower in their study in general population (28%). Overinclusion always a concern and will need to interview for more clarity. References at end (zimmerman) Sparrow/MSU FMRP Behavioral. Science Team 2012

Sparrow/MSU FMRP Behavioral. Science Team 2012 MDQ developed and researched by Hirshfeld and others has been somewhat controversial as a screening tool. In psychiatric settings the sensitivity and specificity is fairly high (73/90) but sensitivity is lower in their study in general population (28%). Overinclusion always a concern and will need to interview for more clarity. References at end (zimmerman) Sparrow/MSU FMRP Behavioral. Science Team 2012

Sparrow/MSU FMRP Behavioral. Science Team 2012 Our attempt to make tool more clear Sparrow/MSU FMRP Behavioral. Science Team 2012

Results Bipolar Disease Dx SToRM present absent Total positive 9 11 20 negative 22 33 42 Data from our STORM research project – working on writing an article about pilot. Sr. resident research project – Dr Brittany Long N = 42 Sensitivity Specificity 100% 67% Prevelance 21%

Discussion – Findings Pilot SToRM Study Sensitivity/specificity SToRM tool is more sensitive than specific in diagnosing mania Sensitivity 100% In the first 42 surveys completed there was no one that had a negative survey for mania or hypomania that carried a clinical diagnosis of Bipolar Disorder

Discussion – Findings Pilot SToRM Study Limited specificity: if a patient had a positive SToRM they did not always have a clinical diagnosis of Bipolar Disorder. Patient with a positive SToRM would need further evaluation to determine the diagnosis.

Self-report Tool for Recognizing Mania We ask days, not minutes or hours to try to see if endures! DSMV has added increased energy as a core part of #1 and #2 Sparrow/MSU FMRP Behavioral. Science Team 2012

Inflated self esteem or grandiosity Decreased need for sleep More talkative than usual or pressure to keep talking Flight of ideas or subjective experience that thoughts are racing Distractibility Increase in goal directed activity Symptoms must be clustered together and occur during the episode, so each question emphasizes that it occurred during the time of elevation/irritability Excessive involvement in pleasurable activities that have a high potential for painful consequences Sparrow/MSU FMRP Behavioral. Science Team 2012

Sparrow/MSU FMRP Behavioral. Science Team 2012 We added some questions to help clarify Sparrow/MSU FMRP Behavioral. Science Team 2012

To qualify as possible mania or hypomania: The answer to #1 and/or #2 MUST be YES (if both answers are NO then criteria not met for mania/hypomania) If yes to #1 then at least 3 items from #3-#9 must be YES If yes to #2 then at least 4 items from #3-#9 must be YES Question A must be moderate or serious. Question B must be at least 4 days for hypomania HOW SERIOUS IMPAIRMENT IS Will ALSO INFLUENCE IDEA OF HYPOMANIA VS MANIA mania Or at least 1 week for Sparrow/MSU FMRP Behavioral. Science Team 2012

Question C if answered YES, helps to make the story more credible Additionally: Question C if answered YES, helps to make the story more credible and speaks to how significant impairment might be. Question D if answered YES, may mean that manic-like symptoms were due to substances Question C – noticed by others. D is about substances associated with episode. WE DID NOT SCORE THESE. Sparrow/MSU FMRP Behavioral. Science Team 2012

When to Use the SToRM in the Family Medicine Office? The patient who: carries a previous diagnosis of Bipolar Disorder is referred for possible acute hypomania or mania is depressed but there’s just something different and worrisome about their story… Sparrow/MSU FMRP Behavioral. Science Team 2012

Demonstration: Diagnosis of Bipolar Disorder Aided by SToRM 20 year old white single female (Sadie) Depression as a teen Activated and odd behavior (including not needing sleep) when on bupropion as a teen Mother Bipolar Disorder Placed on lamotrigine Became very depressed. Not responsive to addition of fluoxetine or sertraline Stopped all meds in college to be “normal” Meds had a lot of side effects and weren’t effective. Hated them. Sparrow/MSU FMRP Behavioral. Science Team 2012

Sparrow/MSU FMRP Behavioral. Science Team 2012 Sadie Recently hospitalized involuntarily Diagnosed with Bipolar Disorder On quetiapine 400 mg at bedtime After discharge goes to a family medicine office Lansing (seen them once before) Felt like she was starting to get depressed – hard to get up, lack of motivation, sadness Sparrow/MSU FMRP Behavioral. Science Team 2012

Sparrow/MSU FMRP Behavioral. Science Team 2012 Sadie’s Context Oldest of 4 sibs Mother has relied on her due to her own mood disorder Small rural town in Michigan Very religious, strict home Her aspiration: To have a college life! Sparrow/MSU FMRP Behavioral. Science Team 2012

Sparrow/MSU FMRP Behavioral. Science Team 2012

Talking to Sadie re: SToRM YES NO Sadie describes herself is never irritable, but very abnormally high. I ask her to describe the recent incident when she ended up in the hospital. Sparrow/MSU FMRP Behavioral. Science Team 2012

Sparrow/MSU FMRP Behavioral. Science Team 2012 YES YES NO YES NO NO Sadie states she was in her bfs family’s home (mood too good for them), felt she had special insights and responsibilities - therefore tried to speak with his parents about their sex life, up all night – or max 3 hrs, racing thoughts, much more interested in sex than usual. YES Sparrow/MSU FMRP Behavioral. Science Team 2012 28

Sparrow/MSU FMRP Behavioral. Science Team 2012 1 week Last 2 questions unscored but can be helpful in dx clarification – Sadie states bf family called police! later stated drank after episode began Sparrow/MSU FMRP Behavioral. Science Team 2012

Sadie’s SToRM Score: Positive Question 1: “yes” 4 positive responses in Question 3-9 (grandiose, needed less sleep, racing thoughts, hypersexual) Moderate Severity (but was hospitalized; minimizing?) Lasted 1 week Unscored items: Others noticed, and not associated with substances Because the mood was elevated, she only need to meet 3 additional criteria. Mania, Bipolar I Sparrow/MSU FMRP Behavioral. Science Team 2012

Approach to Choosing Medication in Suspected Bipolar Disorder PhASE Ph ase of Bipolar Disorder suspected at encounter A cuity S ide effects E ase of use Shift gears to talking about how to approach treatment with Sadie and others. PHASE CHART is another tool we’ve created to organize an approach Sparrow/MSU FMRP Behavioral. Science Team 2012

Sparrow/MSU FMRP Behavioral. Science Team 2012 Phase: Once we think pt. has BPD, What phase of Bipolar Disorder is the patient presenting with now? Sparrow/MSU FMRP Behavioral. Science Team 2012

Ph: Phases of Bipolar Disorder Hypomania/Mania or Mixed (treated similarly) Depression Euthymic, or Maintenance 3 times more likely to be in depression than in mania/hypomania Sparrow/MSU FMRP Behavioral. Science Team 2012

Sparrow/MSU FMRP Behavioral. Science Team 2012 Once you know what phase the patient is in, we move on to ACUITY: How fast do I need to get a response to the drug? Sparrow/MSU FMRP Behavioral. Science Team 2012

Sparrow/MSU FMRP Behavioral. Science Team 2012 A: Acuity How ill is this patient? How urgent is it that the patient improve right away? Medication strategies have varying times of onset of action Sparrow/MSU FMRP Behavioral. Science Team 2012

Sparrow/MSU FMRP Behavioral. Science Team 2012 PhA: Mania/Hypomania Urgent: Mania Consider hospital Maximize mood stabilizer if already present Antipsychotics are fastest (generally use atypicals) Less Urgent: Hypomania Could use low dose antipsychotic for current symptoms For both, consider starting non-antipsychotic mood stabilizer (e.g., lithium, lamictal) for longer term use Back to phase chart to help us make choices. Left side of chart – mania column. Suggests drugs based on both manic phase, urgency. Regarding Li: many pcps don’t feel comfortable rushing dose up, and the Aps (most have efficacy) provide effective control quite fast. Sparrow/MSU FMRP Behavioral. Science Team 2012

PhA: Maintenance Phase Not Urgent May be on program that is concerning in some way Side effects Only on an antidepressant No meds now Consider: nonantipsychotic mood stabilizer like lamotrigine or lithium or valproate We’ll come back to depression and expand on that in a moment since that is the most common Sparrow/MSU FMRP Behavioral. Science Team 2012

Sparrow/MSU FMRP Behavioral. Science Team 2012 PhA: Depression Urgent: Severely depressed Maximizing mood stabilizer already present is first line strategy Quetiapine or olanzapine/fluoxetine Less Urgent: Mild-moderately depressed Consider lamotrigine or lithium Antidepressant role is after mood stabilizer only and questionable Middle column has Depressed phase and levels of urgency of that depression LIMITED PHARM TOOLS. If start AP, consider soon using mood stabilizer with hopes of avoiding long term AP use Sparrow/MSU FMRP Behavioral. Science Team 2012

Approaches to Bipolar Depression Antipsychotics which are FDA approved Quetiapine Olanzapine/fluoxetine (more risky) Lamotrigine Lithium Or can use combination therapies: Adding lamotrogine or lithium or an antidepressant to a strategy already in place We don’t’ have many pharmacologic tools to treat BP depression! International BPD conference. Lithium underused. Sparrow/MSU FMRP Behavioral. Science Team 2012

Sparrow/MSU FMRP Behavioral. Science Team 2012 Quetiapine studies – 2 large studies n=about 500, doses of 300, 600 vs placebo, randomized, double blind: response rates in 1st after about 8 weeks nearly 60% vs. placebo 36%. Remission 50% vs 28%. Not quite as good in second study (Thase et al Efficacy of quetiapine monotherapy in bipolar I and II depression Jl of Clinical Psychopharmacology2006) but still significant. Fairly well tolerated. No manic switching. Sparrow/MSU FMRP Behavioral. Science Team 2012

Sparrow/MSU FMRP Behavioral. Science Team 2012 Zyprexa study. 833 Bipolar I patients. Randomized to placebo, Olanzapine/fluoxetine, and Olanzapine monotherapy. Remission rates at 8 weeks – 24% placebo, 33% olanzapine, 49% combo. Improvemetns as early as 1 week. Side effects. No sig. switching. Sparrow/MSU FMRP Behavioral. Science Team 2012

(Ph) Evidence for the Approaches to Bipolar Depression Lamotrigine Calabrese, JR et al. A Double-Blind Placebo-Controlled Study of Lamotrigine Monotherapy in Outpatients with Bipolar I Depression. J. Clin Psychiatry, Feb 1999; 60:2 Lithium Grandjean, EM, Aubry JM. Lithium: Updated Human Knowledge Using an Evidence-Based Approach Part I. CNS Drugs;2009; 23:3 Lamictal study. N=199. Bipolar I. 7 weeks. 200 mg daily or 50 mg daily. Response: 51% on 200 mg, 41% on 50 mg, 26% placebo Lithium – data is old and hard to evaluate but reviewed by the International Consensus Group on Bipolar I Depressin treatment guidelines and CANMAT and thought to have merit. Merit may be in stabilization, maintenance. Sparrow/MSU FMRP Behavioral. Science Team 2012

Augmentation Strategies Add Lamotrigine? Nierenberg AA, Ostacher MJ, Calabrese JR, et al; and STEP-BD Investigators
Am J Psychiatry. 2006;163:210-216 Add lithium? Add antidepressant? Not if accompanied by manic symptoms Sachs GS, Nierenberg AA, Calabrese JR, et al. Effectiveness of adjunctive antidepressant treatment for bipolar depression. N Engl J Med 2007;356:1711-22 Generally ad considered less safe to add if not on a drug to help prevent mania. Sparrow/MSU FMRP Behavioral. Science Team 2012

Sparrow/MSU FMRP Behavioral. Science Team 2012 Now, before we make final choice of drug - even though we know what we’d like to choose, we need to discuss SE and Monitoring requirements with patient and take our patient into consideration in our choice.NOW WILL GO THROUGH SOME OF PROS AND CONS OF COMMONLY USED DRUGS. LOOK AT MED CHARTS HERE. Sparrow/MSU FMRP Behavioral. Science Team 2012

Sparrow/MSU FMRP Behavioral. Science Team 2012

Sparrow/MSU FMRP Behavioral. Science Team 2012

The Case of Sadie Revisited Hospitalized and diagnosed Bipolar Disorder Discharged back to pcp office on: Quetiapine 400 mg at bedtime Felt like she was starting to get depressed – hard to get up, lack of motivation, sadness Sparrow/MSU FMRP Behavioral. Science Team 2012

Choosing Sadie’s Treatment: PhASE Phase of disorder: What phase is she in? Acuity: How sick is she and how urgent is it that she respond quickly? In hospital? Now? Consider Side Effects and Ease of use of a medication program Sparrow/MSU FMRP Behavioral. Science Team 2012

Sparrow/MSU FMRP Behavioral. Science Team 2012 Sadie’s Treatment Phase: Bipolar I, mania now treated, feels depressed at this time Acuity: Not urgent currently, but was recently very ill; could worsen Side Effects/Ease of Use with current program (quetiapine) Sadie has tolerated quetiapine remarkably well I increased her quetiapine 500, 600 mg/d If wasn’t tolerating quetiapine (hx of failing Lamictal) could consider Lithium. Im actually maximizing product that is in place. Sparrow/MSU FMRP Behavioral. Science Team 2012

Why Pair Psychosocial Treatment with Meds for BD? Medications Only = Residual Symptoms (despite adequate treatment with meds (levels, doses) One study showed 1/3 of patients on meds with residual sx Impact of residual symptoms on course of disease and impairment in cognition and executive function Medication + Psychosocial Intervention = Superior Results Shorter time to recovery Decreased symptoms, improved quality of life and functioning Decreased relapse rates Psychosocial outcomes from med treatment alone are largely unsatisfactory. BPD is hard to control. People tend to have residual symptoms, high recurrence rates, and medication non-adherence. KB has been seeing her for 2 years and she has only been in therapy for the past 6 months but she has had significant improvement since getting into therapy.

Psychosocial Impact of Bipolar Disorder on Individual’s Life Grieving for the lost healthy self Interpersonal difficulties Interruption in career Legal issues Financial issues Job loss Guilt and shame about manic episode Speaking of quality of life and functioning, let’s think for a moment about how BPD impact a person’s life? Sparrow/MSU FMRP Behavioral. Science Team 2012

Risk Factors for an Episode Sleep deprivation Stressful life events Alcohol & drug abuse Inconsistency with medication Family/interpersonal conflict or distress You can see how folks can really get stuck… sometimes the risk factors feed on eachother! Sparrow/MSU FMRP Behavioral. Science Team 2012

Sparrow/MSU FMRP Behavioral. Science Team 2012 Protective Factors Observing/monitoring moods and fluctuating triggers Maintaining regular daily and nightly routines Relying on social and family supports Engaging in regular medical and psychosocial treatment Sparrow/MSU FMRP Behavioral. Science Team 2012

Evidenced-based Psychosocial Interventions for Bipolar Disorders Family Focused Therapy Cognitive Behavioral Therapy Individual and Group Psycho-education Interpersonal and Social Rhythm Therapy Significant improvement in symptoms and functional outcomes These 4 psychosocial approaches have been found to be effective as adjunctive treatment of patients with bipolar.. A number of studies have demonstrated significant improvements in symptoms… decreased relapse rates… increased medication adherence and improved functional outcomes.

Goals of These Psychosocial Interventions for Bipolar Disorder Educate about illness and tx Enhance acceptance of illness Improve monitoring of changes in mood, sleep & vigilance for warning signs of relapse Establish skills for coping with & limiting stress Sparrow/MSU FMRP Behavioral. Science Team 2012

Family Focused Therapy Teach patients and their families about bipolar disorder and disease management (medication, triggers, etc.) Focus on improving communication skills Interpersonal problem-resolution skills Early detection/plan for relapse Typically initiated during or shortly after acute episode STEP-BD research confirmed the efficacy of Family Focused Therapy, when used as an adjunct to pharmacotherapy, to reduce time to recovery, delay relapse/recurrence, reduce relapse rates, improve patient functioning, reduce inter-episode symptoms, improve medication adherence, and increase total time in recovery for adults and teenagers with bipolar disorder over the course of 1 to 2 years Sparrow/MSU FMRP Behavioral. Science Team 2012

Cognitive Behavioral Therapy Psychoeducation regarding illness, stress management, meds Life events scheduling Cognitive restructuring Problem solving Early detection/plan for relapse Generally start when in remission Thoughts Feelings Behavior Traditional CBT approach applied to setting of Bipolar Disorder: Education, Insight, Problem Solving/Coping Strategies, charts… homework… etc. Sparrow/MSU FMRP Behavioral. Science Team 2012

Individual and Group Psycho-education Educational focus geared toward patients, individual or groups (may include family) Improved knowledge of bipolar disorder (triggers, risks, protective factors, treatments, etc.) Increase knowledge of and adherence to medication For patients who are in remission Understand that bipolar is chronic highly recurrent. Identify and avoid triggers, manage symptoms, may engage support person. Sparrow/MSU FMRP Behavioral. Science Team 2012

Interpersonal Social Rhythm Therapy: Psycho-Chronobiological Theory Genetic predisposition to circadian rhythm & sleep-wake cycle abnormalities Social Zeitgeber hypothesis (external time givers) Rhythm disrupting (stressful) life events At the core of IPSRT are routines and relationships… Our whole bodies are like a big clock. Circadian genes are expressed in virtually every organ of the body and regulate organ function, these genes regulate sleep, appetite, energy level, concentration, mood. Internal clock 24 hr. rhythm. It’s no coincidence that these are the same areas affected by mania & depression. Social Zeitgeber – external time keeper … sunrise/set, activities When tracing back to first bipolar episode, one can easily identify a precipitating stressful life event. Individuals with bipolar disorder are highly sensitive to changes in rhythms or routines and have great difficulty resetting themselves once disrupted. Symptoms of depression or mania = changes in mood,appetite, sleep, interest, ability to concentrate, self-esteem… all have a very regular 24 hour rhythm (aware of our sleep, appetite, and energy but may not be as aware of our periods of lowest mood, concentration… sleep thru that) Social Zeitgebers are external time givers – environmental fators with periodicity that help to synchronize the 24 cycle of circadian rhythm: sun rise/set, meal time, regular social activity Interpersonal and Social Rhythm Therapy (IPSRT) is founded upon the belief that disruptions of our circadian rhythms and sleep deprivation may provoke or exacerbate the symptoms commonly associated with bipolar disorder. Its approach to treatment uses methods both from interpersonal psychotherapy, as well as cognitive-behavioral techniques to help people maintain their routines. In IPSRT, the therapist works with the client to better understand the importance of circadian rhythms and routines in our life, including eating, sleeping, and other daily activities. Clients are taught to extensively track their moods everyday. Once routines are identified, IPSRT therapy seeks to help the individual keep the routines consistent and address those problems that arise that might upset the routines. This often involves a focus on building better and healthier interpersonal relationships and skills.

Sparrow/MSU FMRP Behavioral. Science Team 2012 Social Rhythm Keeping a routine is an essential component of IPSRT - Sleep/wake - Meals - Exercise - Activities In addition to our Internal time keeper, circadian rhythms, we have external time keepers… that is our social rhythms or daily routines. A change in a patients job, moving them from first shift to third shift, not only disrupts their social rhythm but also their circadian rhythm! EFFECTS WHEN THEY EAT, WHO THEY INTERACT WITH FRAGMENTED SLEEP Sparrow/MSU FMRP Behavioral. Science Team 2012

Relationship Between Stressful Life Events & Bipolar Episodes Disrupted Social Rhythm Circadian Rhythm Disturbance Recurrence of Bipolar Symptoms Illustration: Relationship stress (loss) > disordered schedule… medication non-adherence > alteration in normal sleep routine (impaired coping) > increased symptoms dog dies… psychologically disruptive and disrupts social rhythm… not just companionship…dog woke me up… take out for walk, make coffee and eat breakfast when fed dog… walked dog again after supper… dog encouraged me to go to bed Psychosocial factors interact with biology… lead to instability and create pathways to recurrence! Sparrow/MSU FMRP Behavioral. Science Team 2012

Focus of IPSRT Education Relationship between mood & life events Importance of maintaining regular daily rhythms & sleep–wake cycles Identification & management of potential precipitants of rhythm disregulation Implement social rhythm stabilization strategies Address interpersonal problem areas Facilitate mourning of loss of healthy self Identification & management of affective symptoms (monitor for relapse) Designed to Target Medication non-adherence, Stressful life events (interpersonal and social roles) and the Disruption in social rhythms by focusing on these areas

Sparrow/MSU FMRP Behavioral. Science Team 2012 IPSRT: 5 Key Areas Getting out of bed 1st social contact Activity (exercise, work, school, etc.) Dinner Going to bed Sparrow/MSU FMRP Behavioral. Science Team 2012

Sparrow/MSU FMRP Behavioral. Science Team 2012 Social Rhythms Metric Sparrow/MSU FMRP Behavioral. Science Team 2012

RCTs of IPSRT in Bipolar Disorder Step-BD MTBD Type of Trial RCT, partially blind RCT partially blind N 293 175 Bipolar Phase Depression Depression, Mania , Mixed Active Group Interventions IPSRT, CBT, FFT IPSRT Control Group Interventions Collaborative care ICM Length 1 year 2 years Results Shorter acute phase longer time to recurrence No shorter acute phase (esp if better SRM scores) Good evidence that IPSRT lengthens time spent in remission and reduces suicidality. One study demonstrated shorter time to remission of depression episodes. Also found that patients with a long history of anxiety or multiple medical problems did not respond as well to IPSRT… perhaps too difficult to focus on tasks of this intervention due to distraction form anxiety or somatic concerns.

Adapting These Approaches to the Family Medicine Office Engage patients & key support(s) in a care partnership Provide education about bipolar disorder Patients with mood disorders are super sensitive to disruption in circadian and social rhythms Importance of sleep & medication adherence Help patient identify and watch for early signs of mania & depression Utilize mood charts and sleep diaries with appropriate follow up Set self-management goals or action plans Sleep Medication Harder to reset

Adapting These Approaches to the Family Medicine Office (cont.) Refer to Therapy Personal list of qualified therapist Pick up the phone… Collaborate! Additional Resources Local Online Books Sparrow/MSU FMRP Behavioral. Science Team 2012

Sparrow/MSU FMRP Behavioral. Science Team 2012 Sleep Diary Sparrow/MSU FMRP Behavioral. Science Team 2012

Sparrow/MSU FMRP Behavioral. Science Team 2012 Mood Chart Show you some sample charts. Want you to know what’s out there and tell your patients about it. Variety of mood charts available on line from very basic to complex. These can help you with diagnosis, monitoring how well medication is working (i.e. target symptoms/behaviors) or to help develop insight related to patterns or triggers. Sparrow/MSU FMRP Behavioral. Science Team 2012

Mood Disorder Action Plan Make this a regular part of visits. If you have a nurse care manager, health coach or other mental health provider in your office, ask them to team up with you to follow up/check in with patient to provide support and encouragement related to the Action Plan… ask if they got in to see therapist, had any trouble getting meds., found someone to help with getting up in the morning. This form is generic. Can create one specific to bipolar disorder or include monitoring for signs of relapse… “the most common symptom when I am getting depressed (or manic) is________” Sparrow/MSU FMRP Behavioral. Science Team 2012

Sparrow/MSU FMRP Behavioral. Science Team 2012 SBIRT Mood disorder disruption related to substance abuse. Think of substance abuse when patients are treatment resistant. Substance abuse can also interfere with accurate diagnosis (mania/hypomania). Use Motivational Interviewing and SBIRT tools to target reduction of quantity of use. Sparrow/MSU FMRP Behavioral. Science Team 2012

Resources: Books Frank, E. (2005). Treating Bipolar Disorder: A Clinician's Guide to Interpersonal and Social Rhythm Therapy. New York, NY: Guilford Press. Bauer, M., Ludman, E., Greenwald, D., & Kilbourne, A. (2008). Overcoming Bipolar Disorder: A Comprehensive Workbook for Managing Your Symptoms and Achieving Your Life Goals. Oakland, CA : New Harbinger Publications. Miklowitz, D. (2011). The Bipolar Disorder Survival Guide: What You and Your Family Need to Know. New York, NY: Guildord Press.

Resources: Online www.nami.org education, support, resources www.moodchart.org retrospective and daily mood charts; research study opportunity www.medhelp.org track mood, sleep, exercise www.psychiatry24x7.com resources, mood chart www.mood247.com mood tracking via daily text message Ellen Frank, MD podcast on SRT and bipolar on NAMI… moodchart=GWU research study participation (Lieberman & Goodwin)

Important Points for Your Patients “Having a mood disorder means that your body clock and daily routines need special attention.” Go to bed and get up the same time everyday Have a stable work/activity schedule Resolve or avoid problem relationships Limit very stimulating or stressful activities & interactions Take medications as prescribed Keep scheduled appointments with your doctor therapist Monitor for early signs of relapse (depression and mania)

Sparrow/MSU FMRP Behavioral. Science Team 2012 Practice Case:Emily 35 year old married woman with 2 young children Depression for about 1 month Hypersomnia Crying Passive suicidal thought Decreased appetite, poor motivation Concerned due to TRD hx Sparrow/MSU FMRP Behavioral. Science Team 2012

Sparrow/MSU FMRP Behavioral. Science Team 2012 Emily History of postpartum depression with her 2nd child; failed 2 SSRIs Family history of unspecified mood disorder (FA) Sparrow/MSU FMRP Behavioral. Science Team 2012

Sparrow/MSU FMRP Behavioral. Science Team 2012

Sparrow/MSU FMRP Behavioral. Science Team 2012 Emily’s SToRM Score Question 1: Yes for no reason 5 positive responses in Questions 3-9 (high opinion of self, needs less sleep, talkative,  projects (cookies), spends too much) Moderate Severity Lasted 4-5 days Says other notice Not associated with substances Hypomania or would this be an overdiagnosis? Seems like it needs corroboration! Sparrow/MSU FMRP Behavioral. Science Team 2012

Sparrow/MSU FMRP Behavioral. Science Team 2012 Emily’s high periods Ignores children Projects started all over the house, unfinished Example: bakes tons of different cookies and talks endlessly about how cookies will change the world Buys hundreds of dollars of jewelry and clothes from internet, television and later returns, regrets We have mother come in who corroborates the cookie story Sparrow/MSU FMRP Behavioral. Science Team 2012

Sparrow/MSU FMRP Behavioral. Science Team 2012 Emily’s Context Husband’s a truck driver away for up to a week at a time Mother is visiting from Texas who has to get home to her own demented mother Father killed himself in 1992 Limited support network Sparrow/MSU FMRP Behavioral. Science Team 2012

How Could we Approach Emily? Pharmacologically (PhASE) What Phase is she in? Acuity: How urgent is she? Side Effects/Monitoring considerations point to what treatment? What treatment are we thinking of? Sparrow/MSU FMRP Behavioral. Science Team 2012

How Could we Approach Emily? Nonpharmacologic Given her presentation, how might we intervene? Psychoeducation Action planning Resources Sparrow/MSU FMRP Behavioral. Science Team 2012

Additional References APA Practice Guidelines for Bipolar Disorder, (2002). Available at www.psychiatryonline.org CANMAT Bipolar Guidelines Update 2007. Bipolar Disorders, 2006; 8: 721-739. Frank, E., Swartz, H., & Kupfer, D. Interpersonal and Social Rhythm Therapy: Managing the Chaos of Bipolar Disorder. Biological Psychiatry, 2000; 48: 593-604. Frank, E., Kupfer, D., & Thase, M, et al. Two Year Outcomes or Interpersonal and Social Rhythm Therapy in Individuals with Bipolar I Disorder. Archives of General Psychiatry, 2005; 62: 996-1004. Goodwin, F. & Jamison, K. (1990). Manic Depressive Illness. New York, NY: Oxford Press. Miklowitz, D. (2011). The Bipolar Disorder Survival Guide: What You and Your Family Need to Know. New York, NY: Guilford Press. Miklowitz, D. A Review of Evidence-Based Psychosocial Interventions for Bipolar Disorder. Journal of Clinical Psychiatry, 2006; 67 (suppl. 11): 28-33.

Sparrow/MSU FMRP Behavioral. Science Team 2012 Emailing Us karen.blackman@hc.msu.edu amy.romain@sparrow.org Sparrow/MSU FMRP Behavioral. Science Team 2012