1 Mental Health Clinical Advisory Group Regular Meeting October 8, 2020 | 1:00PM-3:00 PM | Zoom Virtual Meeting https://www.zoomgov.com/j/1600926885?pwd=NUFPTkdZd3FtbFA2SkNZcy9NemRIQT09 Dial by your location +1 669 254 5252 US (San Jose) +1 646 828 7666 US (New York) Meeting ID: 160 092 6885 Password: 594878 _____________________________________________________________________________________ Officers: Nick Kashey, MD (Chair); Davíd Nagarkatti-Gude (Vice-Chair). Appointed Members: Glena Andrews, Ph.D.; William Beck, PharmD; Chris Bouneff; Keith Cheng, MD; Donald Dravis, MD; Neil Falk, MD; Joan Fleishman, PsyD; George Fussell, MD; Maggie Bennington-Davis, MD; Bob Joondeph, JD; Lori Martin, MSN, PMHNP; Jill McClellan, PharmD; Mario Odighizuwa; Leah Werner, MD. MHCAG webpage: https://www.oregon.gov/oha/HSD/OHP/Pages/PT-MHCAG.aspx TOPIC: BIPOLAR DISORDER AND SPECIAL PAGE TIME FACILITATOR POPULATIONS Call to order ------------ 1:00-1:05pm Nick Kashey/OHA Rollcall Topic: Women of childbearing age 3 1:05-1:25pm Nick Kashey Topic: Youth 3 - 4 1:25-1:35pm Nick Kashey Topic: Geriatric populations 4 1:35-1:45pm Nick Kashey Break ------------ 1:45-1:50pm Nick Kashey Public comment ------------ 1:50-2:00pm Nick Kashey Topic: Anxiety disorders 4 2:00- 2:10pm Nick Kashey Topic: ADHD 4 - 5 2:10-2:20pm Nick Kashey Topic: Substance use 5 2:35-2:50pm Nick Kashey Wrap-up ------------ 2:50-3:00pm Nick Kashey/OHA 2 Next Regular Meeting: November 5, 2020 from 1:00-4:00pm Location: This will be a virtual meeting MHCAG 2020 MEETING SCHEDULE Date/Time Type of Meeting Format November 5, 2020 Regular Virtual meeting 1:00-3:00pm December NO MEETING N/A NO MEETING January 7, 2021 Regular Virtual meeting 1:00-3:00pm 3 Populations requiring special attention when treating Bipolar Disorder 1 - Women of childbearing age • DO NOT USE Valproic Acid or Carbamazepine if pregnant or planning to become pregnant. • Special care needs to be taken when prescribing mood stabilizers for women of childbearing age due to teratogenic effects. • Create plans with the patient: o 1) to minimize the risk of unplanned pregnancies while taking medications, o 2) to manage Bipolar Disorder should the patient wish to become pregnant, and o 3) to treat Bipolar Disorder symptoms should they develop when the patient is pregnant or nursing. • Due to increasing risk of affective disorders, consider a plan to monitor more closely for symptoms during the post-partum period.1 Medication Absolutely Relatively Insufficient Significant Contraindicated Contraindicated Data observational/retrospective data exists Valproic acid X Carbamazepine X Lithium X Lamotrigine X Oxcarbazepine X Typical X antipsychotics Atypical X antipsychotics 2 – Youth Bipolar Disorder is often difficult to accurately diagnose in children and young adults, given a broad differential diagnosis for such symptoms, as well as a high proportion of comorbidity with other psychiatric diagnoses. • Children and young adults are more prone to metabolic side effects from medications. The diagnosis of Bipolar Disorder should be firm before initiating medications. • The lowest effective dose should be used, and periodic reviews should assess for dose reductions, if appropriate. 1 Rodriguez-Cabezas, L. and C. Clark (2018). "Psychiatric Emergencies in Pregnancy and Postpartum." Clinical obstetrics and gynecology 61(3): 615-627. 4 • Patients should be monitored closely for emergent side effects, with a low threshold for medication changes should metabolic side effects develop. 3 – Geriatric Many patients with Bipolar Disorder experience a change in cycling as they age, with cycles generally becoming more frequent and symptoms becoming less intense, often with an increase in manic or hypomanic symptoms relative to depressive symptoms • Medication doses often need to be adjusted to account for changes in factors such as physiology and bioavailability. • Medication side effects may cause more impairment and risk as patients age. • Assessment for dose reduction should occur frequently in this population. o Atypical antipsychotics medications pose an increased risk of cardiovascular mortality. • Psycho-socio-spiritual supports are very important for this population. 4 – Anxiety Disorders Patients with co-occurring Bipolar Disorder and anxiety disorders may experience unique challenges, as their anxiety symptoms may benefit from the use of antidepressants, however their bipolar disorder may become more difficult to manage with the use of antidepressants. • Generally, patients with these co-occurring issues are best served by treating their anxiety without the use of antidepressants. o Consider trying various psychotherapies, relaxation techniques/exercises, EMDR, hypnosis, acupuncture, etc • If an antidepressant is used, clinical practice suggests that SSRI’s or buspirone are the safest options. • SNRI’s appear to present a higher risk of conversion to mania than SSRI’s and should be used with more caution. • TCA’s present a high enough risk to be contraindicated. • Benzodiazepines present no risk of conversion to mania and can be helpful in managing manic symptoms, but they should be used with the usual precautions concerning tolerance/addiction issues. 5 – ADHD Patients with both ADHD and Bipolar Disorder also experience unique challenges, as their ADHD symptoms may benefit from the use of stimulants, however: • Bipolar disorder may become more difficult to manage with the use of stimulants. • Generally, those with these co-occurring issues are best served treating their ADHD without the use of stimulants. o Instead, non-pharmacologic treatments for ADHD should be considered, including behavioral therapies, cognitive behavioral therapy, occupational therapy, increasing physical activity, increasing “green time,” biofeedback, acupuncture, etc. • However, if a stimulant is used, clinical practice suggests that it be used at the lowest dose necessary. 5 • While atomoxetine and buproprion may present a slightly lower risk of conversion to mania than stimulants. o They should be used with caution, as they also carry a risk of conversion to mania. 6 - Substance Use More than 50% of patients with Bipolar Disorder are also diagnosed with a substance use disorder (reference?) and many symptoms of substance intoxication or withdrawal mimic symptoms of mania or depression. • Diagnosis and treatment of Bipolar Disorder in this context often proves difficult. • In general, a diagnosis of Bipolar Disorder should be made only if symptoms (recent or historical) occurred during a period of sobriety lengthy enough that symptoms could not be attributed solely to substance intoxication or withdrawal. • If no such period of sobriety exists, a detailed chronology plotting substance use intensity and affective symptom intensity may be able to establish a connection (or lack thereof) between the 2 issues, thus clarifying diagnoses. • While clarifying diagnosis, consider using non-medication treatments for substance use as these treatments often overlap. • Once a diagnosis is established, medications should be chosen so as to balance clinical effectiveness while minimizing substance-medication interactions. Partial reference List Treatment of bipolar disorders during pregnancy: maternal and fetal safety and challenges Richard A Epstein,1 Katherine M Moore,2 and William V Bobo2 Drug Healthc Patient Saf. 2015; 7: 7–29. Published online 2014 Dec 24. doi: 10.2147/DHPS.S50556 Atomoxetine Induced Hypomania in a Patient with Bipolar Disorder and Adult Attention Deficit Hyperactivity Disorder Vijaya Kumar and Shivarama Varambally1 Indian J Psychol Med. 2017 Jan-Feb; 39(1): 89–91. doi: 10.4103/0253-7176.198954 6 Drug, Healthcare and Patient Safety Dovepress open access to scientific and medical research Open Access Full Text Article REVIEW Treatment of bipolar disorders during pregnancy: maternal and fetal safety and challenges Richard A Epstein1 Abstract: Treating pregnant women with bipolar disorder is among the most challenging Katherine M Moore2 clinical endeavors. Patients and clinicians are faced with difficult choices at every turn, and no William V Bobo2 approach is without risk. Stopping effective pharmacotherapy during pregnancy exposes the patient and her baby to potential harms related to bipolar relapses and residual mood symptom- 1Department of Psychiatry, Vanderbilt University School of Medicine, related dysfunction. Continuing effective pharmacotherapy during pregnancy may prevent Nashville, TN, 2Department of these occurrences for many; however, some of the most effective pharmacotherapies (such as Psychiatry and Psychology, Mayo valproate) have been associated with the occurrence of congenital malformations or other Clinic, Rochester, MN, USA adverse neonatal effects in offspring. Very little is known about the reproductive safety profile and clinical effectiveness of atypical antipsychotic drugs when used to treat bipolar disorder For personal use only. during pregnancy. In this paper, we provide a clinically focused review of the available informa- tion on potential maternal and fetal risks of untreated or undertreated maternal bipolar disorder during pregnancy, the effectiveness of interventions for bipolar disorder management during pregnancy, and potential obstetric, fetal, and neonatal risks associated with core foundational pharmacotherapies for bipolar disorder. Keywords: bipolar disorder, pregnancy, anticonvulsants, antiepileptics, antipsychotics, safety Introduction Bipolar disorders, including bipolar I disorder, bipolar II disorder, and