sign in sign up
<<
Home , Phobia

Objectives Emotional Extremes: Screening • Understand differences between , , & bipolar for I & II disorders

• Describe presentation of bipolar disorders in primary care Ann Kriebel-Kriebel-Gasparro,Gasparro, MSN, FNP, GNP DrNP Student • Be aware of screening ttlools for bibilpolar dididsorder Drexel University • Invitation to participate in a survey about screening for bipolar College of Nursing & Health Professions disorder

• Invitation to participate in focus groups about bipolar disorder

1 2

Major Depressive Disorder (MDD) Major Depressive Disorder (MDD)

•1 in 5 people experience MDD at least once in life • Diabetes, heart disease, autoimmune disease, pain : • MDD is defined as: co-morbid conditions of MDD • Low mood , Inability to experience pleasure (anhedonia) •, environment, & genetics are factors : • or both > 2 weeks combined with cognitive & carriers of short allele of transporter gene vegetative symptoms + distress or impairment in ADLs more prone to depression •Most with MDD have > one episode in lifetime •Gene/s for MDD not isolated : polymorphisms in genes are risk for MDD

•het Rot, M., Mathew, S. J., & Charney, D. S. (2009). Neurobiological mechanisms in major depressive disorder. Canadian Medical Association Journal, 180(3), 305-313.

3 4

The serotonin transporter gene Neurobiology of MDD

•Neuroimaging - MDD may be multiple abnormalities in

interconnectivity of subcortical (especially limbic) & cortical brain

•Lack of cortical regulation of in psychosocial

adversity may explain stress sensitivity, emotional lability, &

suicidality in MDD

5 6

1 Depression is Common

10-14% of patients who present to PCP have Depression

Half of patients treated w/ (AD) respond in weeks

1/3 have remission with one AD

Data shows little variation in efficacy of antidepressants

All AD have some adverse effects & drug-drug interactions

7 8

Antidepressant : SSRIs Medications:

•Constipation, diarrhea, dizziness, HA, , nausea, & Bupropion : (Wellbutrin) – unique, in it’s own class somnolence – common SE for all works on neurotransmitter dopamine • Fluoxetine (Prozac) Also marketed as Zyban – for smoking cessation • Citalopram (Celexa) Bupropion assoc with less than fluoxetine, • Sertraline (Zoloft) 8% > diarrhea paroxetine, & sertaline in comparative effectiveness trials • Paroxetine (Paxil) • Escitalopram (Lexapro) Website from PubMedHealth: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0004898/ http://www.nimh.nih.gov/health/publications/mental-health-medications/complete-index.shtml 9 10

Consequences of Failure to Diagnose & Treat ANXIETY DISORDERS Depression • Social & family relationships damaged

• School failures, jjpob loss & financial dependence

•

• Brain cell loss or process retraction or atrophy

11 12

2 Generalized (GAD) ANXIETY DISORDERS • GAD affects 6.8 million American adults, 2x women as men

• Generalized anxiety disorder (GAD) • Extreme worry - catastrophizizng about health, money, family, or work

• Obsessive compulsive disorder (OCD) • GAD is diagnosed symptoms last > 6 mos

• PtPost-ttitraumatic stress diddisorder (PTSD) • Difficult y concent rati ng, insomni a fa tigue, hea dac hes, musc le ac hes, difficulty swallowing, trembling, irritability, sweating, nausea, frequency, • SOB, & hot flashes (psychomotor & psychiatric symptoms) • Social phobia • SNRI venlafaxine (Effexor) used commonly for GAD

13 14

Obsessive compulsive disorder (OCD) PostPost--traumatictraumatic stress disorder (PTSD)

• Post-traumatic stress disorder (PTSD) is an anxiety disorder that some people • OCD affects 2.2 million American adults & can be accompanied by develop after seeing or living through an event that caused or threatened eating d.o, other anxiety d.o., or depression serious harm or death. According to the 2005 National Comorbidity Survey- • Affects men & women equally, begins in childhood, adolescence, or Replication study, PTSD affects about 7.7 million American adults in a given young adulthood year, though the disorder can develop at any age, including childhood. Symptoms include strong & unwanted memories of the event, bad dreams, • Research shows OCD may be familiar emotional numbness, intense guilt or worry, angry outbursts, feeling “on edge,” • have persistent, upsetting thoughts (obsessions) & use rituals & avoiding thoughts & situations that are reminders of the trauma (compulsions) to control the anxiety these thoughts produce. Most of

the time, the rituals end up controlling them. 15 16

Panic disorder Social phobia

• Sudden attacks of terror, pounding heart, sweatiness, weakness, • Social Phobia, or Disorder, is an anxiety disorder of overwhelming faintness flushing nausea, chest pain, or smothering sensations. anxiety & self-consciousness in everyday social situations.

• Sense of unreality, of impending doom or losing control. • Can be limited to one type of situation — such as fear of speaking, or eating in front of others — or, in most severe form, may be so broad that a person • Mimics heart attack experiences symptoms almost anytime they are around other people.

• Unpredictable – can occur in sleep, peaks in 10 minutes • Sx = persistent, intense, chronic fear of being watched & judged by others, being • Affect 6 million American adults & 2X common in women as men embarrassed or humiliated by own actions. Fear may be so severe it interferes with work or school, & other daily activities. • Often begin in late adolescence or early adulthood -may be inherited • Physical symptoms include blushing, profuse sweating, trembling, nausea, & • Disabling - one-third develop if untreated 17 difficulty talking. 18

3 Antidepressants, antianti--anxietyanxiety Medications, & Beta-Beta-blockersblockers Medications to Treat Anxiety Disorders Treat Anxiety Disorders • For anxiety - antidepressants started at low dose & increased slowly • SSRIs such as fluoxetine (Prozac) + • Tricyclic antidepressants work well for anxiety: – sertraline (Zoloft) + – Imipramine (Tofranil) - panic disorder & GAD. – escitalopram (Lexapro) + – Clomipramine (Anafranil) for OCD. – paroxetine (Paxil) + • Tricyclics started at low doses & increased over time. – citalopram (Celexa) • MAOIs used for anxiety Are all commonly prescribed for panic disorder, OCD, PTSD, & social phobia. • Sometimes phenelzine (Nardil), tranylcypromine (Parnate), & isocarboxazid (Marplan) - food avoidances

19 20

Benzodiazipines for Anxiety Disorders What is the difference between MDD, Anxiety & Bipolar Disorders? • Clonazepam (Klonopin), social phobia & GAD • MDD is a steady state with episodes of low mood – does not have episodes of or hypomania • Lorazepam (Ativan) panic disorder

• Alprazolam (Xanax), panic disorder & GAD • Bipolar disorder is an unsteady state of low & high (ittt(anxiety state –manihia or hypoman i)dia) moods • Benzodiazapines work quickly vs AD

• Beta-blockers can help with physical sx, palpitations • Anxiety is an unsteady state of accelerating anxious moods, tensions, worries, etc

• http://www.nimh.nih.gov/health/publications/mental-health- • Current research – are these different entities or a medications/complete-index.shtml continuum?

21 22

NIMH Definition of Bipolar Spectrum NIMH Position on Bipolar Screening

• NIMH researcher Kathleen Merikangas, Ph.D. & colleagues identified prevalence • Merikangas & colleagues concerned that as people seek treatment for anxiety, rates of 3 subtypes of bipolar spectrum disorder in adults. depression or , providers may not be detecting bipolar disorders

– Bipolar I = recurrent episodes of mania & depression. “Because bipolar spectrum disorder commonly coexists with other illnesses, it is under-

– Bippypolar II milder form of mania called hypomania that alternates with recognized & undertreated. We need better screening tools & procedures for depressive episodes. identifying bipolar spectrum disorder, and to work with clinicians to help them better

– Bipolar disorder not otherwise specified (BD-NOS), sub threshold BPD, have spot these bipolar symptoms,” said Dr. Merikangas. manic & depressive symptoms, but do not meet strict criteria in the Diagnostic & Statistical Manual for Mental Disorders (DSM-IV) • Merikangas KR, et al. Lifetime & 12-Month Prevalence of Bipolar Spectrum Disorder in the National Comorbidity Survey Replication. Archives of General . May 2007; 64. – BD-NOS still can significantly impair those who have it. 23 24

4 Belmaker, R. H. (2004). Bipolar Disorder. New England Journal of Medicine, 351(5), 476-486

25 26

The Course of Unipolar Disorders The Course of Bipolar Disorders

Mania Mania

Depression Depression Depression Depression Mixed state

School Friends Job Marriage Finances Physical health School Friends Job Marriage Finances Physical health 27 28

Mood Disorders are Serious How are bipolar disorders treated?

• Mostly recurrent episodes or chronic illness.

• High suicide risk. • Bipolar disorder, also called manic-depressive illness, is commonly • Treatment often started late & long-term compliance treated with mood stabilizers.

poor. • Sometimes, antipsychotics & antidepressants are used along with a • Early treatment & episode prevention is better than mood stabilizer. responding to each new episode.

29 30

5 Mood Stabilizers Atypical antipsychotics

• Lithium is a very effective mood stabilizer. First mood stabilizer • Olanzapine (Zyprexa), helps with severe or psychotic depression approved by FDA in 1970's for mania & depression – effective in • Aripiprazole (Abilify), which can be taken as a pill or as a shot decreasing suicidal ideations & attempts • Risperidone (Risperdal) • Anticonvulsant medications also are used as mood stabilizers. • Ziprasidone (Geodon) – valproic acid / divalproex sodium (Depakote) • Clozapine (Clorazil), used when not responsive to lithium or – carbamazepine (Tegretol), anticonvulsants – lamotrigine (Lamictal)

– oxcarbazepine (Trileptal). 31 32

Antidepressants The Bipolar Disorders: Epidemiology • Used to treat the depression in manic-depression – should not be used U.S. public health costs of depression est at $53 bill alone in bipolar disorder – can exascerbate mania & has high risk of $33 bill rt to lost employment. suicide APNs r/o physical causes of depressive or anxiety sx – Fluoxeti ne (Prozac ) Studies show that bipolar II disorder has a higher rate of suicide – paroxetine (Paxil) than – sertraline (Zoloft) Bipolar I is more extreme – more hospitalizations BP II more chronic, misdiagnosed as depression

33 34

Mood Disorders: Bipolar Disorder Misdiagnosis Common

• Misdiagnosis of bipolar disorders as unipolar depression & • The World Health Organization ranks bipolar disorder (BPD) as comorbidity among axis I disorders presents a strong argument for the one of the top 10 causes of disability in world routine screening of all depressed patients for bipolar disorders • incidence as high as 5% in the U.S. (Baldassano, 2005; Benazzi, 2003; Hirschfeld & Vornik, 2004) • BPDI will often present to the emergency room with symptoms of • 2000 National Depressive & Manic-Depressive Association severe mania or , but this is not true of patients with BPDII Survey of individuals with BPD reported that 69% of patients disorders, who more often present to their primary care practice with received an initial misdiagnosis & one third had a delay in correct depressive symptoms. diagnosis of 10 years

35 36

6 Mood Disorders – why the lag time? The Bipolar Disorders: Lag Time in Diagnosis

• Bipolar disorder is fatal in a high proportion of patients from • Bipolar II disorder is harder to diagnosis, often complications of risk-taking behavior, comorbid medical missed, patients are often suffering in silence (do illnesses, & especially suicide

• The long lag time in correct diagnosis could be significantly not complain to physician for many reasons, &

reduced if APNs in primary care were actively involved in physicians are too busy to screen) screening depressed patients for bipolar disorder

37 38

Practice Gap: Ultimate Risk Is Suicide Screening Tools for Bipolar Disorder

• Currently the literature does not link depression & bipolar disorder (BPD) & a knowledge & research gap exists. The majority of literature links suicide to depression & there is a paucity of research on screening depressed patients for bipolar disorder. Contrary to what was previously thought, the risk of suicide is high in BPDI; but even higher in BPDII

39 Baldassano, 2005 40

Mood Disorder Questionnaire Questionnaire

YES NO 1. Has there ever been a period of time when you were not your usual self YES NO and...... you were so easily distracted by things around you that you had ...you felt so good or so hyper that other people thought you were not your trouble concentrating or staying on track? normal self or you were so hyper that you got into trouble? ...you had much more energy than usual? ...you were so irritable that you shouted at people or started fights or ...you were much more active or did more things than usual? arguments? ...you were much more social or outgoing than usual, for ...you felt much more self-confident than usual? example, you telephoned friends in the middle of the night? ...you got much less sleep than usual & found you didn’t really miss it? ...you were much more interested in sex than usual? ...you were much more talkative or spoke faster than usual? ...you did things that were unusual for you or that other people ...thoughts raced through your head or you couldn’t slow your mind down? might have thought were excessive, foolish, or risky?

41 42

7 Mood Disorder Questionnaire References

Baldassano, C. F. (2005). Assessment tools for screening & monitoring bipolar disorder. YES NO Bipolar Disorders Supplement, 1, 8-15. 2. If you checked YES to more than one of the above, have several of Benazzi, F. (2003). Underdiagnosis of Bipolar II Disorders in the Community. Journal of these ever happened during the same period of time? Please Clinical Psychiatry, 64(9) Belmaker, R. H. (2004). Bipolar Disorder. New England Journal of Medicine, 351(5), 476-486 cilircle one response only. het Rot, M., Mathew, S. J., & Charney, D. S. (2009). Neurobiological mechanisms in major 3. How much of a problem did any of these cause you — like being depressive disorder. Canadian Medical Association Journal, 180(3), 305-313. unable to work; having family, money, or legal troubles; getting into Medications, accessed online at: http://www.nimh.nih.gov/health/publications/mental-health- arguments or fights? Please circle one response only. medications/complete-index.shtml No problem Minor problem Moderate problem Serious problem

43 44

References

Merikangas KR, et al. Lifetime & 12-Month Prevalence of Bipolar Spectrum Disorder in the National Comorbidity Survey Replication. Archives of General Psychiatry. May 2007; 64. Conference Evaluation

Ramsley, S. E. (2007). Unipolar or bipolar depression? Improving diagnostic confidence with the adult patient. Journal of the American Academy of Nurse Practitioners, 19(4), 172-178. Online evaluations at: www.pacnp.org/conference

45 46

8