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

2. 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

3. 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

4. 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?

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

6. 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)

7. 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

8. 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

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

10. 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

11. 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)

12. 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)

13. 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

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

15. 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

16. 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

17. 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)

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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?

27. 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

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

29. 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

30. 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)

31. 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

32. 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

33. 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)

34. 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

35. 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)

36. 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

37. 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

38. 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

39. 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

40. 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

41. 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.

42. 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.

43. 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)

44. 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

45. 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?

46. The end
Thank you! Any questions?