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Bipolar
disorders
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Medical Editors
Kath OConnor
Catherine Dodgshun
Bipolar disorders
Editor
Nicole Kouros
Case 1
Case 2
Case 3
13
Case 4
18
Case 5
21
References
24
Resources
25
26
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Authors
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David Castle
Leon Piterman
Kay Jones
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This unit of check focuses on bipolar disorders with clinical scenarios relating to diagnosis of depressive, hypomanic
and manic episodes; diagnosis of the bipolar disorders; assessment of risk to the patient and others; identification
of predisposing and precipitating factors, and pharmacological and nonpharmacological management of the bipolar
disorders. The authors of this unit bring a wealth of clinical, research and teaching experience to the topic.
The authors are:
Andrew Gleason BSc, MBBS(Hons), Senior Registrar, Primary Mental Health Team, St Vincents Hospital,
Victoria. His clinical interests include neuropsychiatry, old age psychiatry, and consultation-liaison psychiatry
David Castle MBChB, MSc, MD, MRCPsych, FRANZCP, Chair of Psychiatry, St Vincents Hospital and the
University of Melbourne, Victoria. His research and clinical interests include longitudinal care for people with
psychotic disorders, bipolar disorders, substance abuse, and medical problems associated with psychotic
disorders
Leon Piterman AM, MBBS, MD, MMed, MEdSt, MRCP, FRCP, FRACGP, Head, School of Primary Care, Monash
University, Victoria. His clinical and research interests lie in the areas of cardiovascular disease, mental health
and medical education
Kay Jones BSW, MTD, PhD, Senior Research Fellow, Department of General Practice, Monash University,
Victoria. Her research areas include chronic disease management (osteoarthritis, obesity, mental health), and
knowledge translation including uptake of guidelines and information technology. Current research and education
development include online activities about osteoarthritis, depression and bipolar disorder.
The learning objectives of this unit are to:
display increased confidence in the diagnosis of hypomania, mania and the bipolar disorders and recognise the
differing clinical contexts in which the bipolar disorders may present
display an increased awareness of the possibility of a bipolar disorder in patients presenting with depression
display increased confidence in the assessment of risk in the bipolar disorders
understand the role of pharmacological and nonpharmacological strategies used in the bipolar disorders
understand the role of the GP in the care of patients with bipolar disorder in regard to monitoring, collaborative
continuing care and management of physical and psychological comorbidities and social repercussions
display increased confidence in monitoring the use of lithium and detecting lithium toxicity
appropriately assess when to refer a person with suspected or diagnosed bipolar disorder to a psychiatrist.
This issue marks the conclusion of my role as medical editor of the check program. Iam commencing a new
role as a medical editor with Australian Family Physician, alongside senior medical editor, Dr Carolyn OShea and
medical editor, Dr Rachel Lee. I wouldlike to extend a warmwelcome to the incoming check medical editor, Dr
Catherine Dodgshun.
Working on check has been an extremelyrewarding experience. I am grateful to all theauthors and reviewers I
have worked withfor the generous gift of their time and expertiseand to the wonderful admin, editing, graphic
design and IT staff for all their hard work.
We hope this unit will help you to more confidently assess and manage patients who present with bipolar disorders
in the general practice setting.
Best wishes
Kath OConnor
Medical Editor
Case 1
Case 1
Adam presents with depression
Adam, aged 26, is an internet technology
consultant. He presents with a 3 month history of
progressive lowering of mood which is worse in
the morning. He experiences no pleasure in any
activities. He has trouble falling asleep, wakes
3 hours before his alarm, and is unable to get back
to sleep. He has no appetite and has lost 5 kg. He
reports trouble functioning at work and feels guilty
about this. There is no clear precipitant.
Question 1
What is your differential diagnosis for Adams presentation?
Further history
Adam lives with his girlfriend and has no past medical or
psychiatric history. He smokes marijuana once every few
months and binge drinks up to 15 standard drinks about once
per month. His grandfather died of suicide at age 42 but the
family never talks about this.
Physical examination, full blood count, urea, electrolytes,
creatinine, liver function and thyroid function tests are all
normal. Adam is commenced on venlafaxine 75 mg per day.
This is well tolerated and increased to 150 mg per day
2 weeks later.
Three weeks after this, Adams girlfriend, Caity, comes
to see you without Adam. She is teary and distressed.
She says that Adam is not his usual self. He has become
uncharacteristically irritable, is easily distracted, and is talking
much more than usual. He is sleeping only a few hours each
night but has a lot of energy. Caity thinks he might have slept
with another woman, as he didnt come home one night.
Adam told her that he is going to be the next Bill Gates and is
planning on using all his savings to set up his own company.
He doesnt think anything is wrong and refuses to seek
medical attention.
Question 4
What is the differential diagnosis now?
Question 2
What are some of the risks associated with Adams symptoms?
Question 5
What are the risks associated with a manic episode?
Question 3
How would you assess Adams risk of suicide?
Case 1
Question 6
Question 9
What advice will you give to Caity? How will you manage this
situation?
Question 10
Further history
Adam was taken to hospital under the Mental Health Act
after being assessed by the on call psychiatry team. He spent
3 weeks as an inpatient and was discharged on sodium
valproate 500 mg twice per day and olanzapine 10 mg at
night. The discharge diagnosis was manic episode due to
antidepressant. Adam now has a case manager who he sees
weekly and his medications are managed by a psychiatry
registrar. Adam has received some education but no specific
psychological interventions. Although he doesnt think
anything was ever wrong, he has been taking his medication.
Question 7
Does Adam have bipolar disorder?
Case 1 Answers
Question 8
What is the typical first presentation of bipolar disorder?
Answer 1
The differential diagnosis in Adams case includes both psychiatric
and organic/medical conditions. Possibilities that could give rise to
this symptom complex are psychiatric conditions such as a mood
disorder (eg. major depressive disorder, bipolar disorder, dysthymic
disorder), anxiety disorder, personality disorder, eating disorder,
drug and/or alcohol abuse or withdrawal. In addition, a wide range
of organic/medical conditions could give rise to Adams symptoms.
These include metabolic disorders such as thyroid disease, infection
and sleep related disorders. Table 1 outlines the wide range of
psychiatric and medical conditions that can cause depressive
symptoms.
Answer 2
With symptoms suggestive of depression there is a risk of the patient
harming themselves as well as a risk of the patient harming others.
Risks include:
suicide
drug and/or alcohol abuse
relationship breakdown
Case 1
Organic/medical conditions
Malignancy
Sleep related disorders, especially sleep apnoea
Answer 5
Potential risks associated with a manic episode include:2
excessive spending
financial problems.
Answer 3
Assessing risk of suicide in depression includes the following.
Answer 6
You could ask Caity whether Adam knows she has come to see you
and if he is happy with her discussing her concerns with you. You
could also ascertain whether she thinks she can convince Adam to
come and see you for a consultation, or if she could try to encourage
him to present to a mental health service or emergency department
or to accept an assessment from the local outreach on call psychiatric
team (see Resources on call services are available in most
metropolitan areas of Australia).
Advice to Caity could include:
explaining what might be causing Adams behaviour (eg. mania,
drugs, medication) but importantly that further evaluation is needed
in order to be able to determine the cause of Adams symptoms and
initiate appropriate treatment
emergency contingency management, for instance, if Caity feels that
Adams symptoms or behaviour are placing her or someone else at
immediate risk of harm, she should contact the police
Case 1
Answer 7
Adam does not qualify for a diagnosis of bipolar disorder at this stage
under International Classification of Diseases (ICD-10)3 or Diagnostic
and Statistical Manual of Mental Disorders (DSM-IV-TR)4 (the most
commonly used diagnostic systems) because his manic episode was
induced by an antidepressant.
Case 1
feel irritated?
have an increased interest in sex?
feel angry?
Answer 8
The first presentation of bipolar disorder is typically with depression.
People with bipolar disorder frequently seek help from a number of
professionals over a period of years before a diagnosis is made. One
study reported that people had seen a mean of four doctors, and
over one-third had waited 10 years before an accurate diagnosis was
made.6,7
It is important for the clinician to consider when assessing every
patient with depression whether it is a depressive episode of bipolar
disorder. It is important for the clinician to be aware that the absence
of past psychiatric history does not exclude previous hypomania. It is
essential to ask specifically about symptoms that could suggest past
manic/hypomanic episodes in everyone who presents with depression
because such symptoms may not be volunteered by the patient.
Screening for mania/hypomania can be extremely challenging,
even for experienced psychiatrists. If unsure, refer the patient to a
psychiatrist or mental health service. A diagnosis of bipolar disorder
has a major impact on the patient, and mood stabilisers can have
significant side effects. Similarly, an antidepressant-induced manic
episode can have major morbidity.
Answer 9
The cross-sectional features of a depressive episode are not reliable
in distinguishing bipolar from unipolar depression, but some features
are more common in bipolar depression. These include recurrent
episodes, short duration of episodes, early age of onset, feelings
of worthlessness, low self esteem, social withdrawal, hypersomnia,
hyperphagia, weight gain, atypical features (eg. leaden paralysis),
mood lability, psychotic features, psychomotor retardation, and a family
history of bipolar disorder. Signs suggestive of bipolar disorder in
depressed patients are listed below:8
worse or wired when taking antidepressants
hypomania in the patients history
irritable
psychomotor retardation or agitation
Answer 10
Your initial and ongoing management of Adam includes:
establishing rapport and maintaining a healthy therapeutic
relationship with Adam and Caity
psychoeducation and support for Adam, Caity and his family
assessment and management of Adams comorbidities
ensuring Adam understands the risks of marijuana use
monitoring Adams drug and alcohol use
utilising mental health treatment plans (Medicare Item Numbers:
2710 or 2702, 2712 and 2713) to arrange consultations and
referrals9
developing and coordinating team based care with appropriate
mental health professionals (eg. a psychiatrist, psychologist,
community mental health team)
considering psychotherapeutic options: psychoeducation, cognitive
behavioural therapy (CBT), interpersonal and social rhythm therapy
and family therapy have all shown benefit as adjunctive treatments10
providing advice and support for Adam regarding diet, physical
exercise and sleep routine
discussing early warning signs with Adam and Caity,11 and involving
them in developing a crisis plan
monitoring moods with a mood chart is extremely useful11
monitoring for medication side effects, including metabolic effects:
check his weight/body mass index (BMI), waist circumference and
lipids1214
performing haematological and liver function tests every 3 months
after commencing sodium valproate for the first year, then annually.12
The frequency of GP review would depend on clinical need, as well
as on how often Adam is seen by a doctor at the public mental health
service. After being discharged from hospital, he should probably have
a medical review at least weekly until his clinical situation settles.
Case 2
Case 2
Sue complains of depression and
irritability
Question 2
What is your differential diagnosis?
Question 1
Is menopause associated with depression?
Question 3
What are the symptoms and signs of mania and hypomania? What
factors distinguish mania from hypomania?
Further history
About 10 months ago, Sue had a 4 month period of pervasive
low mood, associated with poor sleep and an increase in
appetite. Her symptoms resolved spontaneously, but after
a brief interlude of euthymia, a 6 month period of sustained
irritability followed.
Sue felt great during this time, and it is only since Bill moved
out that she began to consider the veracity of his complaint
that she was irritable all day, every day. She was also sleeping
less than usual but felt energetic and fully rested. She had
an increased interest in sex and spent large amounts of time
writing several books, but didnt complete any of them. Bill had
commented that she didnt stop talking which contrasted to
her usual somewhat taciturn state. These symptoms resolved
a few weeks ago.
Sue describes herself as usually placid and agreeable.
In spite of this, a number of relationships in the past
have ended during times when her partner said she was
uncharacteristically irritable and restless for periods of weeks
to months. The first episode took place in her mid-20s. She
was diagnosed with depression a number of times by her GP,
but found that antidepressants always caused insomnia and
made her disinhibited. She has never seen a psychiatrist and
she doesnt use drugs or alcohol.
Question 4
What investigations should be done?
Case 2
Question 5
Question 8
Further history
Sue is referred to a primary mental health service (a public
service that provides psychiatric assessment and management
advice to GPs, available in some parts of Australia) for
clarification of her diagnosis. The psychiatrist diagnoses her
with bipolar II disorder and recommends that Sue have a trial
of lithium and psychological treatment.
Question 9
Sue asks for more information. What resources can you refer her to?
Question 6
How do people with bipolar II disorder typically present?
Question 10
Sue tells you that she had CBT once, but it didnt suit her, and
may have made things worse. Given that she is currently euthymic,
should you initiate psychological treatment? If so, what treatments
would you consider?
Question 7
Is bipolar II disorder less severe than bipolar I disorder?
Case 2
Question 11
Question 13
case 2 AnswerS
Question 12
Answer 1
Many physical conditions are associated with psychiatric symptoms,
and menopause is no exception (Figure 1). There is no clear
evidence that menopause is a risk factor for the development of
psychiatric illness the majority of women do not experience a
major depressive episode at the time of menopause, but some
women may be particularly vulnerable at this life stage. Most at risk
of depression are those who have a past history of mood problems,
as well as those who experience many or intense physical symptoms
during menopause.15
Menopause
Low mood
Fatigue
Irritability
Poor concentration
Anhedonia
Insomnia
Vasomotor disturbance
(hot flushes, diaphoresis)
Suicidality
Feelings of worthlessness
Irritability
Osteoporosis
Psychomotor agitation/retardation
Libido change
Figure 1. Changes associated with menopause and depression, with overlap shown.16 Adapted and reproduced with permission from Physicians Postgraduate Press
10
Answer 2
The differential diagnosis includes:
bipolar II disorder, most recent episode hypomanic
bipolar I disorder,
most recent episode manic
most recent episode mixed
recurrent episodes of major depression with irritability
physical illness such as an endocrine disorder
adjustment disorder
personality disorder
(Sue also has a concurrent menopausal syndrome).
Note that bipolar I disorder is characterised by at least one manic
or mixed episode; bipolar II disorder is characterised by least one
major depressive episode and at least one hypomanic episode but
no manic or mixed episodes.
Answer 3
Mania is a syndrome characterised by a distinct period of persistently
and abnormally elevated, expansive, or irritable mood, accelerated
speech, racing thoughts with flight of ideas, increased activity and
reduced need for sleep (Table 2).6 The severity and duration of the
mood disturbance, impairment in social and occupational functioning,
and presence or absence of psychotic features distinguish a manic
from a hypomanic episode. The term hypomania is used when
symptoms are less severe and of shorter duration.6 In ICD-10,
hypomania is characterised by a persistent mild elevation of mood
not accompanied by hallucinations or delusions.3 In DSM-IV-TR, a
Case 2
Answer 7
While hypomanic episodes are by definition less severe than manic
episodes, the overall course of bipolar II disorder is associated with
substantial morbidity that is often no less severe than bipolar I.
High rates of occupational, leisure and relationship dysfunction are
common, and bipolar II disorder may be more recurrent than
11
Case 2
12
Case 3
Case 3
Sally hasnt been her usual self
Question 3
How would you clarify Sallys diagnosis?
Question 4
Sallys father has bipolar disorder. How does this affect her risk of
developing bipolar disorder?
Question 1
What is your differential diagnosis for Sallys presentation?
Further INFORMATION
After Sallys foot is sutured, she becomes abusive and starts
yelling in the emergency department. Physical examination
and investigations are normal apart from cannabinoids in
her urine. She is admitted to the acute psychiatry ward.
She settles on an atypical antipsychotic and sodium valproate.
She is discharged 2 weeks later.
Two months after this she presents to you as her GP, having
become depressed. She has recommenced smoking marijuana
on a daily basis and is drinking 68 standard drinks every
other day. She also thinks she might be pregnant.
Question 5
Question 2
List some of the aspects of Sallys physical health which you need
to address.
13
Case 3
Question 6
Question 9
If Sally was not pregnant what approaches could you use to treat
Sallys depression?
Question 7
How would you address Sallys ongoing substance use?
Case 3 AnswerS
Answer 1
The differential diagnosis is:
manic or mixed episode of bipolar disorder
hypomanic episode
substance (cannabis or amphetamine) precipitated mood or
psychotic disorder
mood disorder or psychotic disorder due to a general medical
condition
schizophrenia
schizoaffective disorder.
Question 8
What are the stages of behavioural change? How would you
structure the questions you ask about a patients stage of change?
What intervention would you consider for each stage?
Answer 2
Acutely, one of the most characteristic effects of intoxication
with Cannabis sativa is euphoria.23 In people who use cannabis
frequently or are cannabis dependent, rates of depression are
elevated, although there does not appear to be an increased risk of
depression associated with infrequent cannabis use. There are no
systematic studies of cannabis and bipolar disorder.24
In Sallys case, marijuana intoxication itself is not an adequate
explanation for her symptoms. A drug precipitated mood disorder
(mania) is possible, ie. she has underlying bipolar disorder that was
triggered or exacerbated by cannabis use.
Drug and alcohol use comorbidity is common in people with bipolar
disorder. Furthermore, bipolar disorder is frequently associated
with other comorbid psychiatric conditions. Anxiety disorders
such as obsessive compulsive disorder are particularly common.
Comorbid conditions worsen the outcome of bipolar disorder.25
They should be screened for and treated.
14
Case 3
Answer 3
Sallys diagnosis could be clarified by considering the possibility of
substance-induced symptoms resulting from intoxication, chronic
use or withdrawal (Table 4), or a nonsubstance-induced disorder
and employing direct questioning toward this.
Answer 4
Affective disorders tend to aggregate in families. Relatives of
bipolar sufferers have an increased risk of both unipolar depression
and bipolar disorder. The risk of first degree relatives of those with
bipolar disorder developing the condition is about 510 times that
of the general population.26
Answer 5
The following aspects of Sallys physical health need to be
addressed.
Pregnancy testing and contraception given that many
pregnancies are unplanned, it is important to discuss the
possibility of pregnancy and contraception options with all
women with possible bipolar disorder. One should plan in
advance for pregnancy wherever possible so that adequate
support and medical review can be ensured. Various
contraceptive options are available including condoms, the
contraceptive pill (in the appropriate dose) and etenogestrel
implant, with the latter being a suitable option where compliance
may be a problem
Prevention of sexually transmitted infections including use of
condoms and screening for sexually transmitted infections
including tests for chlamydia and gonorrhoea (a first pass urine
for polymerase chain reaction [PCR] or endocervical swabs for
PCR endocervical swabs should not be taken in pregnancy)
and trichomonas (a high vaginal swab) and serology for hepatitis
B (HepBsAg, HepBsAb) hepatitis C, HIV and syphilis (rapid
plasma reagin)
Drug use this is discussed further in Answer 7 and 8 of this
case.
Addressing aspects of Sallys health may proceed concurrently
with addressing aspects of her psychiatric condition.
Answer 6
Sodium valproate is teratogenic. It is therefore best not to use it
first line in women of child bearing potential. There is a 15% risk
of neural tube defects compared to a population risk of 0.03%.
Facial and cardiac malformations can also occur. Folic acid
supplementation is recommended.27 Other side effects of sodium
valproate include weight gain, transient hair loss, and rarely, hepatic
toxicity. It is also associated with polycystic ovarian syndrome.12,22
No pharmacotherapy for bipolar disorder is risk free during
pregnancy, and no psychotropic medications have been thoroughly
studied with regards to safety in pregnancy and lactation.
First generation antipsychotics may confer a lower foetal risk
15
Case 3
Answer 8
The stages of behavioural change are precontemplation,
contemplation, preparation, action, maintenance and relapse.
Questions can be structured around each of these stages. It is
importance that the questions are open ended, nonjudgemental, and
actively involve the patient to participate in their own decision making
in each of these stages. The type of intervention varies depending on
the stage of Sallys behavioural change. Education is appropriate at
the precontemplation phase, exploring the pros and cons of change
is appropriate at the contemplation stage, determining strategies for
change is appropriate at the preparation stage, assisting the patient
with implementation is helpful at the action phase, reviewing relapse
prevention strategies is important at the maintenance phase and
assisting in change is relevant at the relapse stage. Table 6 outlines
the stages of change involved in altering certain behaviours and
the interventions a health professional can undertake to support a
patient through the change in that behaviour.
Answer 9
Approaches to deal with Sallys depression include the following.
Dealing with Sallys illicit drug and alcohol use, first with the
strategies described above, before altering her prescribed
medication then assessing her residual depressive symptoms once
she has not been using illicit drugs for a period of time
Dealing with her depression concurrently, as depression can
predispose an individual to use illicit drugs and alcohol in an
attempt to relieve their symptoms
Checking compliance with, and optimising dosage of, her current
antipsychotic and sodium valproate
Considering the use of psychological strategies such as supportive
psychotherapy, CBT, interpersonal and social rhythm therapy
Providing advice regarding diet, physical exercise and sleep routine.
Feedback
An antidepressant is sometimes added to a medication
regimen that consists of a single prophylactic medication.
Adding an antidepressant could cause cycle acceleration (ie.
frequent exacerbations of bipolar disorder) so if this option is
pursued, it is recommended that the patient be referred to a
psychiatrist, be closely monitored and that consideration be
given to withdrawing the antidepressant within 12 months of
successful resolution of bipolar depression.
Note that antidepressant monotherapy is not recommended in the
bipolar disorders because of the risk of inducing rapid cycling.
16
Case 3
Characteristics
Intervention
Precontemplation
May be resigned
Feeling of no control
Preparation
Support patient
Assist in renewing process of change
17
Case 4
Case 4
Sam lost his job
Sam is 24 years of age. He is a labourer who is
currently on unemployment benefits. Since he lost
his job 2 months ago he has been feeling irritable.
His mood has been going up and down, from
feeling depressed to feeling really good. At the
time of presentation he is not enjoying anything
in life and feels worthless. He has a decreased
need for sleep. His thoughts have been racing. He
feels hyperactive, cant concentrate, and is easily
distracted. He is more talkative than usual, he has
lost a few kilograms in weight and has had some
thoughts that life is not worth living but has no
suicidal plans or intent.
Further history
Sam is provisionally diagnosed with a major depressive
episode and commenced on escitalopram 10 mg at morning.
On review 1 week later, his symptoms are worse. In particular,
he feels more irritable but is still having periods where he feels
very good. He is sleeping less, now only 3 hours per night.
His thoughts are more racy.
Question 2
How does this information change your differential diagnosis?
Question 1
What is your differential diagnosis for Sams presentation?
Further information
Sam is referred to a psychiatrist and diagnosed with bipolar
disorder, mixed episode. The selective serotonin reuptake
inhibitor (SSRI) is stopped, and sodium valproate 400 mg twice
per day is commenced.
Over the next few weeks, his irritability, talkativeness, and
racing thoughts settle. Dominant depressive symptoms remain,
consistent with a major depressive episode. In particular, Sam
complains of poor sleep. As Sams GP, you discuss this with
the psychiatrist, who suggests that quetiapine 200 mg at night
be added.
Sam visits again and says that his mood is generally good
now, he feels calmer and his sleep has returned to normal,
but he still cant concentrate on things. He says his poor
concentration and distractibility are longstanding. He says
he read something about adult attention deficit hyperactivity
disorder (ADHD) in a magazine and asks if he might have this.
Question 3
Could this be adult ADHD? How would you differentiate between
bipolar disorder and ADHD?
18
Case 4
Further history
Since he started school Sam has always had attention
problems. He never really managed any school subjects and
was held back in year 2. Then he just pushed through until he
left school at age 15. He was always a fidgety child, and never
sat still. He was a risk taker and always in trouble.
Question 4
How might you attempt to further support a diagnosis of adult ADHD?
Further information
Sam is commenced on methylphenidate 10 mg per day by his
psychiatrist (who has a special interest in adult ADHD), increasing
daily to maximum effect. Stimulant prescription is commenced
on the condition that he have regular urine drug screens for illicit
substances given his history of use. Valproate and quetiapine
are continued. He is referred for neuropsychological testing to
further elucidate his deficits related to ADHD, so that these can
be targeted specifically with the aim of maximising his
socio-occupational functioning. He tolerates methylphenidate
well, with sustained even mood and marked improvement in
attention. However, if he misses quetiapine, he finds that he has
trouble sleeping and becomes cranky.
Question 7
What nonpharmacological treatments would be useful to Sam?
Question 5
What is the relationship between bipolar disorder and ADHD in
adults?
Case 4 Answers
Answer 1
The differential diagnosis is:
major depression with irritability
anxiety disorder
substance-induced mood disturbance
bipolar disorder (mixed episode)
Question 6
adjustment disorder
What further treatment options might you consider and what are the
risks and benefits?
adult ADHD
cluster B personality disorder/traits.
Answer 2
The exacerbation of symptoms makes a mixed episode more likely.
A mixed episode is defined as a period of at least 1 week where
symptoms of both a manic episode and a major depressive episode
are present nearly every day. Symptoms of mania were present
in the initial presentation, including a decreased need for sleep,
increased talkativeness, subjective experience that thoughts are
racing, and distractibility.
19
Case 4
Answer 3
A good history is key (Table 7 and 8 ) in determining the cause of
poor concentration or distractibility, and can prevent an iatrogenic
exacerbation of symptoms that may occur with inappropriate therapy.
Answer 4
The diagnosis of adult ADHD is controversial, but it appears that a
subset of children with ADHD go on to have symptoms as adults, with
significant social and occupational consequences.30,31
Note that ADHD does not tend to develop in adulthood without
preceding symptoms of ADHD in childhood. Evidence suggestive
ADHD
Degree of overlap
Psychomotor agitation
Hyperactivity
Extensive
Impulsive
Impulsivity
Extensive
Distractibility
Inattention
Extensive
Irritability
Ubiquitous
Extensive
More talkative
Moderate
Elation
Little
Grandiosity
Little
Little
Difficulty settling
for sleep
Little
Little
Little
Bipolar depression
ADHD
Degree of
overlap
Depressed mood
Dysphoria
Extensive
Insomnia
Difficulty settling
Extensive
Irritability
Irritability
Extensive
Difficulty concentrating
Inattention
Extensive
antidepressants
Psychomotor agitation
Hyperactivity
Moderate
benzodiazepines
Disinhibition
Impulsivity
Moderate
Weight loss/gain
Moderate (after
stimulant treatment)
Psychomotor retardation
Little
Little
Hypersomnia
Little
Little
Thoughts of death/suicidality
Little
20
Case 5
Case 5
Is Mrs Smith depressed?
You have just taken over the care of patients in a local
nursing home from a GP who retired. The nursing staff ask
you to see Gladys Smith, a 70 year old lady who is in lowlevel care.
Mrs Smith moved to the nursing home 1 month ago, after
being discharged from an old age psychiatry unit. Before
her admission, she had been living independently. The
immediate precipitant for her admission was a fire in her
flat. When the fire department arrived, Mrs Smith was
running around the perimeter of the building claiming that
she was the Messiah and that the blaze was started by
demons. She was taken to hospital, diagnosed with a manic
episode and transferred to the old age psychiatry unit.
Basic blood tests, including thyroid function, B12, folate,
and syphilis serology were normal. A cerebral MRI showed
mild generalised atrophy thought to be consistent with age
related changes. There was also evidence of small vessel
ischaemia. She was commenced on lithium. When her manic
symptoms resolved, she had occupational therapy and
neuropsychological assessments. Mini Mental State Exam
(MMSE) was 25/30. She was found to have mild executive
functioning and verbal memory deficits. It was felt that she
needed supported accommodation because of decreased
mobility due to osteoarthritis, and she was approved for lowlevel care. Mrs Smith initially settled into the nursing home
well. She socialised with the other residents and participated
in activities.
Mrs Smith has had one previous psychiatric admission
15 years ago for a manic episode and at that time was
Question 1
Question 2
Is it possible that Mrs Smith has dementia? How could you tell?
21
Case 5
Question 3
What is your short term management plan?
Case 5 Answers
Answer 1
Differential diagnoses in this scenario include delirium, dementia and
depression. Delirium secondary to lithium toxicity is the most likely
cause of this presentation. Note that delirium is often misdiagnosed
as depression.4042 Lithium toxicity can occur at lower levels in the
elderly than in a younger population, even at supposedly therapeutic
levels (see Answer 4).
The recently commenced celecoxib could have caused this.
Angiotensin converting enzyme inhibitors, diuretics, and nonsteroidal
anti-inflammatory drugs can increase lithium levels. Lithium toxicity
can also be caused by reduced fluid intake, fluid loss from vomiting,
diarrhoea or excessive sweating, or by deliberate or inadvertent
overdose.22
Question 4
Over the longer term, what monitoring and follow up should Mrs
Smith have?
Delirium
Dementia
Onset
Rapid
Insidious
Primary deficit
Attention
Course
Fluctuating
Progressive
Question 5
Duration
Days to weeks
Months to years
Consciousness
Clouded
Clear
22
Case 5
Answer 3
Delirium is a medical emergency. Lithium toxicity can be fatal. Mrs
Smith should be transferred immediately to the nearest emergency
department via ambulance. You or the nursing home staff should
inform her relatives.
Lithium toxicity is treated by withdrawal of lithium, intravenous fluid
resuscitation, and electrolyte replacement, as well as treatment
of any underlying medical condition. Haemodialysis may be
needed.22,43
Answer 5
Psychotherapy is effective in older people but is frequently not
offered.44
Psychological approaches can also be helpful for patients with
cognitive impairment, although the approach needs to be modified.
In such cases it would be wise to consider referral to someone with
experience in providing therapy to people with cognitive impairment,
such as an old age psychiatrist (psychogeriatrician), or a psychologist
with relevant training and experience.
With respect to Mrs Smiths current state, psychological
interventions (aside from those aimed at assisting reorientation) are
clearly contraindicated in delirium. Once her delirium has settled, it
would be sensible to provide some psychoeducation to Mrs Smith,
and the nursing staff at the aged care facility. In particular, it would
be useful to ensure the nursing staff understand:
early warning signs of depression, mania, and delirium
what to do if she appears to be relapsing into mania or
depression, or if she appears to be delirious.
In the future, if she relapses into mania or depression, more
extensive psychotherapeutic treatment should be considered.10
Answer 4
Regular monitoring of lithium levels, renal function, and thyroid
function should be undertaken:
creatinine clearance can decrease with age, affecting serum
lithium levels
23
References
30. Kessler RC, Adler L, Barkley R, et al. The prevalence and correlates
of adult ADHD in the United States: results from the National
Comorbidity Survey Replication. Am J Psychiatry 2006;163:71623.
10. Lauder SD, Berk M, Castle DJ, et al. The role of psychotherapy in
bipolar disorder. MJA 2010;193:S31S35.
32. Ward MF, Wender PH, Reimherr FW. The Wender Utah Rating Scale:
an aid in the retrospective diagnosis of childhood attention deficit
hyperactivity disorder. Am J Psychiatry 1993;150:88590.
34. Scheffer RE. Concurrent ADHD and bipolar disorder. Curr Psychiatry
Rep 2007;9:41519.
14. Conn TA, Sernyak MJ. Metabolic monitoring for patients treated
with antipsychotic medications. Canadian Journal of Psychiatry
2006;51:492501.
15. Dennerstein L, Alexander JL. Mood and menopause. In: Castle DJ,
Kulkarni J, Abel KM, editors. Mood and anxiety disorders in women.
Cambridge University Press: Cambridge, 2006;212241.
16. SoaresC, Taylor V. Effects and management of the menopausal
transition in woman with depression and bipolar disorder. J Clin
Psychiatry 2007;68(Suppl 9):1621.
17. Royal Australian and New Zealand College of Psychiatrists Clinical
Practice Guidelines Team for Bipolar Disorder. Australian and New
Zealand Clinical Practice Guidelines for the Treatment of Bipolar
Disorder. Aust N Z J Psychiatry 2004;38:280305.
20. Lam-Po-Tang J, McKay D. Dr Google, MD: a survey of mental healthrelated internet use in a private practice sample. Australas Psychiatry
2010;18:1303.
21. National Collaborating Centre for Mental Health. Bipolar disorder: the
management of bipolar disorder in adults, children and adolescents,
in primary and secondary care. National Clinical Practice Guideline
Number 38. Leicester and London: The British Psychological Society
and The Royal College of Psychiatrists, 2006.
24
resources
PROFESSIONAL RESOURCES
beyondblue: www.beyondblue.org.au
Black Dog Institute: www.blackdoginstitute.org.au
Victorian Better Health Channel: www.betterhealth.vic.gov.au/
bhcv2/bhcarticles.nsf/pages/Bipolar_disorder?open
MoodSwings is an online self-help program for bipolar disorder.
Intake of registrations may vary with time. Information on this site
is also relevant. www.moodswings.net.au
Multicultural Mental Health Australia: www.dhi.gov.au/
Multicultural-Mental-Health-Australia/default.aspx.
The following online self management programs are directed at
depression and anxiety, but are applicable to bipolar disorder,
particularly as anxiety is a common comorbidity:
Moodgym: www.moodgym.anu.edu.au
E-couch: http://ecouch.anu.edu.au
Anxiety online: www.anxietyonline.org.au.
ERRATUM
In the January/February check unit, Figure 5 (page 9) was
incorrect.
The following are the correct pathways for faecal-reducing
substances >0.25%, and faecal pH <7.0:
YES Trial of lactose-free formula or lactase-treated breast milk
NO Trial of cows-milk-free formula or cows-milk-free
maternal diet.
The editors apologise for any confusion or inconvenience.
25
Bipolar disorder
In order to qualify for 6 Category 2 points for the QI&CPD
activity associated with this unit:
read and complete the unit of check in hardcopy or
online at the gplearning website at www.gplearning.
com.au, and
log onto the gplearning website at www.gplearning.
com.au and answer the following 10 multiple choice
questions (MCQs) online
complete the online evaluation.
If you are not an RACGP member, please contact the
gplearning helpdesk on 1800 284 789 to register in the
first instance. You will be provided with a username and
password that will allow you access to the test.
The expected time to complete this activity is 3 hours.
Please note
From January 2011, there will no longer be a Category 1
activity (ALM) associated with check units. This decision
was made due to a lack of interest in this activity. The
RACGP apologises for any inconvenience caused by
this change
Do not send answers to the MCQs into the check
office. This activity can only be completed online at
www.gplearning.com.au.
If you have any queries or technical issues accessing the
test online, please contact the gplearning helpdesk on
1800 284 789.
Question 1
Wendy, age 52, presents with a 9 month history of amenorrhoea, mild
hot flushes, decreased libido, irritability and a loss of interest in her
usual activities. She also feels an increased need for sleep and has
gained 6 kg in weight. Your first step in management is to:
A. prescribe hormone replacement therapy (HRT) to treat her
menopausal symptoms
B. discuss the overlap between symptoms of depression and
menopause and suggest a trial of treatment for her depressive
symptoms
C. tell her all women have to go through menopause and it will pass
soon enough
D. prescribe both HRT and an antidepressant from the outset
E. recommend she keep a food and exercise diary and return in
3 months.
Question 2
Susie, 37 years of age, is a patient of yours who presents with acute
mania. You transfer her to hospital. Upon discharge she has been
stabilised on lithium. When treating a patient with lithium:
26
Question 9
When you see Alice she appears a little vague but is oriented to time,
place and person. The nurse says she was much worse overnight.
Which of the following is true?
A. More severe delirium is associated with a greater degree of
hyperactivity
B. Vagueness in this age group is always due to dementia
Question 6
Sally comes to see you to discuss her son Marcus, age 25. Marcus
was recently diagnosed with a manic episode after presenting with
symptoms of hyperactivity, difficulty concentrating, and excessive
spending. Sally brings in an article she found on the internet about
adult attention deficit hyperactivity disorder (ADHD). She asks if this
condition could better explain Marcus symptoms. In differentiating
between ADHD and a manic episode the most useful symptom/s to
elucidate are:
27
notes
28