Managing Bipolar Disorder and Schizophrenia in Primary Care Dr Claire Littlewood Consultant Old Age Psychiatrist

Overview Introduction Primary Care focus Diagnosis / classification When to refer, and who to? Treatment guidelines Primary care monitoring Prognosis and longer term management Case studies

Schizophrenia Classification (how to understand the psychiatrist’s letter!) ICD10 defines 4 main subtypes (+ undifferentiated /other categories) General characteristics: psychosis i.e.. positive symptoms (delusions and hallucinations), abnormal affect/volition (negative symptoms), first rank symptoms Cognitive deficits often develop over time

Schizophrenia diagnosis cont. Psychosis (delusions and hallucinations) is a symptom with various aetiologies e.g.. Schizophrenia Psychotic mood disorder Dementia Delirium Alcohol / substance misuse How to distinguish?

First rank symptoms Thought echo / insertion / withdrawal Thought broadcasting Delusional perception Passivity Third person auditory hallucinations Strongly suggestive of schizophrenia

Subtypes of schizophrenia, and why do we care? Paranoid (mainly positive symptoms) Hebephrenic (mainly negative symptoms – rapid onset) Catatonic (rare) Simple (slow onset negative symptoms, generally not preceded by psychosis) (Schizo-affective disorder) (Paraphrenia – late onset schizophrenia)

Positive/negative symptoms Why do we care? – because the relative presence/absence of these helps predict course/ treatment response and prognosis. Generally – negative symptoms are harder to treat and suggest poorer prognosis Each person with schizophrenia has their own unique combination of symptoms

Typical presentation to primary care (age 15-35) Prodromal period – characterised by decline in personal functioning (memory, concentration, odd behaviour and/or ideas, disturbed mood, social withdrawal etc) i.e. predominantly negative symptoms Usually followed by acute episode of positive symptoms – common point of presentation

Co-existent disorder may ppt. presentation Depression Anxiety Substance misuse Personality disorder NB Schizophrenia has lifetime prevalence of 1%

Great variation in presentation Some have positive symptoms briefly, others for years Some have no prodrome Some have no positive symptoms Some have just one acute episode which responds to treatment Some have residual negative symptoms for years which may be interspersed with acute episodes

When / where to refer General rule - urgently refer any first (and subsequent) presentation psychotic symptoms (positive symptoms) to secondary care (unless obvious delirium) Better prognosis if treated early Could commence anti-psychotic in primary care if experienced Refer to CMHT (single access point)

Treatment guidelines NICE CG82 March 2009 Schizophrenia (update) Physical – antipsychotics Psychological (offer CBT to all and family therapy if appropriate) – both may be started in acute phase or later (Psychological input would be in secondary care)

Antipsychotics Typical (older) and atypical (newer) Typicals block dopamine Atypicals block dopamine to lesser extent, and also have effects on other neurotransmitters e.g.. 5HT – hence have some effect on negative symptoms Efficacy same (NB Clozapine) Difference is side effect profiles (and effects on negative symptoms) Choice made by patient and professional Good practice to do ECG first especially if cvs risk/history

Common side effects Typicals cause following through dopamine blockade: Parkinsonian symptoms (block dopamine) Akathisia Tardive dyskinesia Atypicals cause above too but to lesser extent

Common side effects cont. Atypicals are lore likely than typicals to cause following: Weight gain Increased chance developing diabetes Sexual dysfunction In higher doses, movement disorders as for typicals

Anti-cholinergics Used to treat parkinsonian side effects / akathisia Good practice to reduce dose anti-psychotic first to see if side effects lessen (secondary care) Abuse potential Cause cognitive problems in elderly Best used as prn

Tardive dyskinesia Longer term side effect Continual movements mouth, tongue, face 1 in 20 Best treatment is to reduce/stop antipsychotic Anticholinergics tend to make it worse (hypothesis of TD being related to cholinergic deficiency)

Antipsychotics cont Avoid combinations of antipsychotics (secondary care) If stable on typicals and tolerating etc – leave! Issues re stelazine Withdrawal should be gradual with regular monitoring Monitor for relapse for at least 2 years post withdrawal (usually secondary care) Depot antipsychotics will always be started in secondary care

Ongoing monitoring in Primary Care (after acute episode) NICE states ‘offer people with schizophrenia whose symptoms have remained stable (on or off treatment) the option to return to primary care for further management’ NICE also states: consider re-referral to secondary care if relapse, risk, poor treatment response, non-concordance, problematic side effects, co morbid substance misuse etc

Physical health monitoring in Primary Care Annual, with focus on CVS (higher risk CVS disease and DM than general population) Lipid levels Plasma glucose / TSH Weight Smoking / alcohol BP

Prognosis High risk relapse if stop meds in 1-2 yrs post acute episode After just one episode 25% chance remission, so for most chronic course If more than one episode and stop meds, usually recurs within 6 mnths More negative symptoms = worse prognosis

Summary of schizophrenia Individual presentations vary greatly Positive (including first rank) and negative symptoms First acute episode (largely positive symptoms) usually ppts presentation to primary care Psychosis is a symptom with Various aetiologies

Summary cont Typical presentation is prodrome (mainly negative symptoms) followed by acute episode (mainly positive symptoms) Co-morbid mental health problems common Most have a chronic course interspersed with acute episodes Acute episodes should be managed in secondary care as should Risk, poor treatment response, non-concordance, problematic side effects, co morbid substance misuse

Summary cont Antipsychotics mainstay treatment of acute episodes Typicals/atypicals have same efficacy/different side effects Psychological therapies (CBT/family) Primary care have key role in referring acute episodes, monitoring physical health and longstanding stable schizophrenia Negative symptoms assoc. with worse prognosis

Case study Nigel is 19. He started at a local university 6/12 ago to do computer science, but failed to attend lectures after the first few weeks. His concentration declined, and he became more and more socially withdrawn. One day he became very agitated, stating there were hidden cameras in his bedroom spying on him. He is diagnosed with schizophrenia by a psychiatrist

Case study cont. Could Nigel’s schizophrenia have been identified at an earlier stage? He responded well to risperidone, and is discharged back to primary care once stable. How long should he continue on Risperidone for? What’s his longer term prognosis? When/why might you re-refer him?

Bipolar affective disorder Defined (ICD10) as two or more episodes of abnormal mood – one of which must be mania/hypomania A single manic/hypomanic episode is not bipolar Repeated episodes (2 or more) of mania/hypomania are classified as bipolar

Hypomania Mild elevation of mood (includes irritability) Increased energy / activity Decreased need for sleep Pressured speech/ thought Over familiarity NOT psychotic symptoms

Mania More extreme form of hypomania May occur with or without psychotic symptoms (e.g.. grandiose delusions) Behaviour can be very risky e.g.. aggression, recklessness (e.g.. sexual, financial) Significant physical risk, especially in elderly

Diagnosis for each affective episode noted e.g. Bipolar disorder, current episode moderate depression Bipolar disorder, current episode manic with psychotic symptoms Bipolar disorder, current episode mixed (mixture or rapid alteration of manic and depressive symptoms)

When to refer to CMHT (NB may go to home treatment etc) NICE CG38 Bipolar disorder Urgently refer new or suspected cases with mania or severe depression who pose risk to self / others Also refer patients with a 4 (or more) day history over activity / disinhibition, or a history of such activity

If existing bipolar disorder managed in primary care: Refer urgently if relapse / risk etc Refer for review if deterioration e.g.. mood disturbance, more frequent acute episodes, co-morbid mental health issues, poor concordance etc Consider referring a new patient with existing bipolar who registers with the practice

Other NICE points to note: Limited evidence for treating bipolar II disorder (hypomania and not mania) (so use recommendations for bipolar I) Term ‘mood stabiliser’ not used Antimanic drugs (antipsychotics, lithium, valproate) Prophylactic drugs i.e.. any drugs used for long term management (antipsychotics, lithium, valproate)

Managing acute (hypo)manic episodes (secondary care) Consider stopping antidepressant Antipsychotic (olanzapine, risperidone or quetiapine). If response inadequate, consider adding Li or valproate Li or valproate may be used before antipsychotic if symptoms not severe / previous response (avoid valproate in women of child bearing age) Manage mixed episodes as for manic

Managing acute (hypo)manic episodes in secondary care Short term benzos may be helpful Carbamazepine not routinely used for acute mania (if already taking, consider adding anti-psychotic)

Managing depressive episodes within bipolar disorder Again – secondary care probably If prescribe antidepressant, need to also consider antimanic drug and or mood stabiliser / prophylactic agent SSRIs first line, as for unipolar depression Psychological treatments not recommended in acute affective episodes

Long term management of bipolar Often remain in secondary care (usually runs chronic and recurrent course – often length of acute episodes increases (and time between decreases) with increasing age Prophylaxis: Lithium, Olanzapine or valproate (combinations may be used) If ineffective: lamotrigine or carbamazepine Antidepressants not routinely continued long term Psychological interventions e.g. CBT are recommended if relatively stable/ non acute

Primary care has key role in physical health monitoring Bipolar pts have higher levels physical morbidity/mortality than general popn. Annual Lipid levels, incl. cholesterol if over 40 yrs Plasma glucose /TSH Weight Smoking / alcohol BP

Primary care monitoring of specific drugs Li level every 3-6/12 and U and Es /TSH every 6/12 Carbamazepine and valproate: FBC and LFTs every 6/12 Carbamazepine: U and Es every 6/12

More on lithium Aim for 0.4-0.8 mmol/l Elderly especially prone to toxicity Levels can be affected by ACE inhibitors, diuretics, NSAIDs Toxicity symptoms include GI upset, tremor, ataxia,confusion,convulsions

Summary of Bipolar Affective Disorder Defined (ICD10) as two or more episodes abnormal mood, one of which must be mania/hypomania Hypomania is a mildly elevated mood without psychosis, mania is a more extreme elevation (+/- psychosis) and often with assoc. risky behaviour.

Summary cont. Urgently refer to secondary care any new presentations hypomania/mania or severe depression, esp. if risks Refer existing bipolar patients if relapse, deterioration, substance misuse etc Drug treatment consists of antimanic drugs and prophylactic drugs (olanzapine, lithium, valproate) and anti-depressants (SSRIs first line). Benzos may be useful.

Summary cont. Longer term management usually in secondary care Includes prophylactic agents (not usually anti-depressants) and psychological input (CBT) Primary care key role in annual physical health checks and blood monitoring for Lithium etc (NB Ace inhibitors, diuretics and NSAIDs)

Case study Andrea is 23 yrs, and has been on fluoxetine long term for recurrent depression. She comes to see you for a routine review and admits to having spells of feeling very excited and energetic. She hadn't thought it important to mention this before

Case study cont. Is it appropriate to refer Andrea at this stage, and does she need an urgent appt? Should you stop the antidepressant medication and/or give an anitmanic medication e.g. Lithium Andrea is prescribed Olanzapine by the psychiatrist as a prophylactic agent. What monitoring do you need to do?

The end Thank you! Any questions? claire.littlewood@shsc.nhs.uk