1. The Manic Patient A Patient-Centered, Evidence-Based Diagnostic and Treatment Process A Presentation for SOMC Medical Education A Presentation for SOMC Medical Education Kendall L. Stewart, MD, MBA, DFAPA January 21, 2011 1 My aim is to offer practical insights you can put to use in your professional life. 2 Please let me know whether I have succeeded on your evaluation forms.

2. Why is this important? After listening to this presentation, you will be able to answer the following questions: –Why is this important? –How do these patients present? –What are the diagnostic criteria?diagnostic criteria –What is the differential diagnosis? –What is the treatment? –What are some of the treatment challenges? The lifetime risk of Bipolar Disorder is 1 to 2-percent.Bipolar Disorder The concordance rate is –65 to 85-percent in monozygotic twins, and –20-percent in dizygotic twins. Bipolar illness occurs in relatives with bipolar disorder much more frequently. The peak age of onset is between 20 and 25 years. 1,2 Mania responds better to treatment than does depression. The prognosis depends on the severity of the underlying illness, the response to treatment and the patient’s compliance.prognosis 1 A history of hypomania in the patient who presents with recurrent depression is easy to miss. 2 The occurrence of a manic episode in older patients should raise concern about underlying organic pathology.

3. What specific diagnoses are included here? Bipolar Disorders Bipolar I Disorder Bipolar II Disorder 1Bipolar II Disorder Cyclothymic Disorder Bipolar Disorder NOS Mood Disorder due to General Medical Condition (GMC) Mood Disorder due to General Medical Condition (GMC) Substance-Induced Mood Disorder 2 Substance-Induced Mood Disorder Mood Disorder NOS 1 Be sure to ask depressed patients and their families detailed questions about unrecognized hypomania. 2 I once treated a college professor who became floridly manic after being dosed with steroids.

4. What is natural history of Bipolar I Disorder? Normal Life

5. What is natural history of Bipolar II Disorder? Normal Life

6. What is natural history of Cyclothymic Disorder? Normal Life

7. How do these patients present? A 27-year-old graduate student was brought to the ED by his fiancée. “He’s had a personality change in the past two weeks.” “He’s been more irritable and suspicious.” “He has not slept at all for the past three nights.” “He is convinced that his research thesis will become the ‘new bible of the computer age.’” “Fearful that his ideas will be stolen, he has created a complicated secret code so that ‘only I and my prophets can understand the text.’” “He’s been dressing in a bizarre way to keep secret agents from following him.” 1,2,3 The patient initially refused to speak with the physician, but then the patient saw that a syllable in the physician’s name was the Latin word for “trust.” The patient then talked incessantly and incoherently about the project that would “rock the world.” The patient was hoarse. He was easily distracted by the ambient sounds in the ED. He was incensed that the physician thought anything was wrong. He only reluctantly agreed to come into the hospital because his fiancée was able to persuade him that he would be safe there. Listen to a bipolar patient here.here 1 These people can be very persuasive. 2 One of my patients was convinced that Crystal Gaye has stolen his country song. 3 Sometimes truth is as strange as delusion. A patient said he had been working on an electric fence.

8. What are the diagnostic criteria? A distinct period of expansive, elevated or irritable mood Lasts at least one week or requires hospitalization Three or more of the following have been present to a significant degree: –Inflated self-esteem –Decreased need for sleep –Increased talking –Racing ideas –Being more distractible –Increased psychomotor activity –Excessive involvement in pleasurable but risky activities Not a mixed episode Significant impairment Not substance-induced. 1 Manic patients are a challenge to interview. Listen attentively for a time with emotional detachment. Don’t argue. Watch for sudden irritability. Keep interviews short. Get the history from family members. 2 Manic patients demand immediate attention. I was attending a hospital picnic in the Black Hills.

9. What associated features might you see? Lack of insight Resistance to treatment Excessive, dramatic writing Sexual experimentation 1 Increased religiosity Increased spending Increased irritability or hostility Physical aggression Difficulties with the law Reports of heightened senses Catatonia Abrupt shift in mood Depressive symptoms Mixed symptoms Rapid cycling 2 Rapid cycling Inappropriate behavior Psychotic symptoms 1 A number of my manic patients have declared themselves homosexual only to be puzzled by that later when in remission. 2 This is coded when four or more mood episodes have occurred in the previous 12 months.

10. What is the differential diagnosis? Normal elation –Winning the lottery 1,2 Other mood disorders –Bipolar II disorders –Cyclothymic Disorder –Bipolar Disorder NOS Mania secondary to a general medical condition –Multiple sclerosisMultiple sclerosis –Brain tumorBrain tumor –Cushing’s syndromeCushing’s syndrome Substance-induced mania –CocaineCocaine Grandiosity secondary to other psychiatric disorders –SchizophreniaSchizophrenia –ParanoiaParanoia 1 Losing can trigger a mood disorder too. 2 I was making rounds in the ICU at Mercy Hospital years ago, and observed a sad staff member.

11. What is the treatment? Mania –Reassure the family. 1 –Make sure the patient is safe. –Consider hospitalization. –Follow an evidence-based algorithm for the treatment of bipolar disorder.algorithm –Consult a psychiatrist. –Begin lithium carbonate 300 mg QID and titrate to therapeutic blood level. 2lithium carbonate –Consider another mood stabilizer or antipsychotic drug. Psychosis –Begin antipsychotic drugs Suicidal risk –Conduct a careful risk assessment. –Document your assessment. –Take appropriate precautions. Insomnia –Consider the short-term use of your favorite sleeper if the antipsychotic drug does not do the trick. Other comorbid disorders –Diagnose and treat these conditions vigorously. –Be careful about using antidepressants since these may trigger rapid cycling. Maladaptive attitudes and behaviors –Counseling is not helpful during a full-blown manic episode. Education and self help –Provide educational resources. –Recommend a daily exercise regimen. –Recommend a healthy diet. –Suggest healthy distractions. –Recommend meditation. –Recommend online resources with caution. –Recommend self help groups with caution. 1 During a florid manic phase, these patients looks a lot sicker than they really are. 2 Remember, lithium is the only effective drug against suicide.

12. What are some of the treatment challenges? These patients are notoriously non-compliant. 1non-compliant A trusting therapeutic relationship is your most effective tool. 2therapeutic relationship These patient will regularly convince you they are fine; their families always know when they are getting manic, and family members always turn out to be right. You only have a narrow window to start adjunctive anti- manic medications. Many of these patients do not respond to lithium alone. You must follow lithium levels, TSH, BUN and creatinine levels regularly. Untreated or inadequately-treated episodes result in worsening over time. Relapses are harder to treat over time. Their episodes of depression are much more difficult to treat. Consider quetiapine or a combination of olanzapine and fluoxetine.quetiapineolanzapine fluoxetine 1 A family physician colleague made a house call and found all of the medications he had previously prescribed. 2 After many years of partial remission, a patient wanted to go off lithium and begin a herbal cure.

13. The Psychiatric Interview A Patient-Centered, Evidence-Based Diagnostic and Therapeutic Process Introduce yourself using AIDET 1.AIDET Sit down. Make me comfortable by asking some routine demographic questions. Ask me to list all of problems and concerns. Using my problem list as a guide, ask me clarifying questions about my current illness(es). Using evidence-based diagnostic criteria, make accurate preliminary diagnoses. Ask about my past psychiatric history. Ask about my family and social histories. Clarify my pertinent medical history. Perform an appropriate mental status examination. Review my laboratory data and other available records. Tell me what diagnoses you have made. Reassure me. Outline your recommended treatment plan while making sure that I understand. Repeatedly invite my clarifying questions. Be patient with me. Provide me with the appropriate educational resources. Invite me to call you with any additional questions I may have. Make a follow up appointment. Communicate with my other physicians. 1 A cknowledge the patient. I ntroduce yourself. Inform the patient about the D uration of tests or treatment. E xplain what is going to happen next. T hank your patients for the opportunity to serve them.

14. Where can you learn more? American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, 2000Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision Sadock, B. J. and Sadock V. A., Concise Textbook of Clinical Psychiatry, Third Edition, 2008 1Concise Textbook of Clinical Psychiatry, Third Edition Flaherty, AH, and Rost, NS, The Massachusetts Handbook of Neurology, April 2007 2The Massachusetts Handbook of Neurology Stead, L, Stead, SM and Kaufman, M, First Aid© for the Psychiatry Clerkship, Second Edition, March 2005First Aid© for the Psychiatry Clerkship, Second Edition Klamen, D, and Pan, P, Psychiatry Pre Test Self-Assessment and Review, Twelfth Edition, March 2009 3Psychiatry Pre Test Self-Assessment and Review, Twelfth Edition Oransky, I, and Blitzstein, S, Lange Q&A: Psychiatry, March 2007Lange Q&A: Psychiatry Ratey, JJ, Spark: The Revolutionary New Science of Exercise and the Brain, January 2008Spark: The Revolutionary New Science of Exercise and the Brain Medina, John, Brain Rules: 12 Principles for Surviving and Thriving at Home, Work and School, February 2008Brain Rules: 12 Principles for Surviving and Thriving at Home, Work and School Stewart KL, “Dealing With Anxiety: A Practical Approach to Nervous Patients,” 2000Dealing With Anxiety: A Practical Approach to Nervous Patients,” 1,2 Please note that you must master all of the information in a basic neurology textbook and a basic psychiatry textbook to do well on the comprehensive, standardized final examination.

15. Where can you find evidence-based information about mental disorders? Explore the site maintained by the organization where evidence-based medicine began at McMaster University here.here Sign up for the Medscape Best Evidence Newsletters in the specialties of your choice here.here Subscribe to Evidence-Based Mental Health and search a database at the National Registry of Evidence-Based Programs and Practices maintained by the Substance Abuse and Mental Health Services Administration here.here Explore a limited but useful database of mental health practices that have been "blessed" as evidence-based by various academic, administrative and advocacy groups collected by the Iowa Consortium for Mental Health here.here Download this presentation and related presentations and white papers at www.KendallLStewartMD.com. www.KendallLStewartMD.com Learn more about Southern Ohio Medical Center and the job opportunities there at www.SOMC.org.www.SOMC.org Review the exceptional medical education training opportunities at Southern Ohio Medical Center here.here

16. How can you contact me? 1 Kendall L. Stewart, M.D. VPMA and Chief Medical Officer Southern Ohio Medical Center Chairman & CEO The SOMC Medical Care Foundation, Inc. 1805 27th Street Waller Building Suite B01 Portsmouth, Ohio 45662 740.356.8153 StewartK@somc.org KendallLStewartMD@yahoo.com www.somc.org www.KendallLStewartMD.com 1 Speaking and consultation fees benefit the SOMC Endowment Fund.

17.  Safety  Quality  Service  Relationships  Performance   Safety  Quality  Service  Relationships  Performance  Are there other questions? www.somc.org Terry Johnson, DO OUCOM 1991 Ryan Foor, DO OUCOM 2005