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Unit 468 March 2011

Bipolardisorders

Independent learning program for GPs

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Medical Editors

Kath O’Connor

Catherine Dodgshun

Editor

Nicole Kouros

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Jason Farrugia

Graphic Designer

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Authors

Andrew Gleason

David Castle

Leon Piterman

Kay Jones

Reviewer

Andrew Baird

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Published by

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Bipolar disordersUnit 468 March 2011

From the editor 2

Case 1 Adam presents with depression 3

Case 2 Sue complains of depression and irritability 8

Case 3 Sally hasn’t been her usual self 13

Case 4 Sam lost his job 18

Case 5 Is Mrs Smith depressed? 21

References 24

Resources 25

QI&CPD Program requirements 26

The five domains of general practice

Communication skills and the patient-doctor relationship

Applied professional knowledge and skills

Population health and the context of general practice

Professional and ethical role

Organisational and legal dimensions


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check Bipolar disorders

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 Vincent’s 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 Vincent’s 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 osteoar thritis, 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. I am commencing a new

role as a medical editor with Australian Family Physician , alongside senior medical editor, Dr Carolyn O’Shea and

medical editor, Dr Rachel Lee. I would like to extend a warm welcome to the incoming check medical editor, Dr

Catherine Dodgshun.

Working on check has been an extremely rewarding experience. I am grateful to all the authors and reviewers I

have worked with for the generous gift of their time and expertise and 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 O’Connor

Medical Editor

FROM THE EDITOR

2


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check Bipolar disorders CASE 1

FURTHER HISTORY

Adam lives with his girlfr iend 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, Adam’s 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 didn’t 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 doesn’t think anything is wrong and refuses to seek

medical attention.

QUESTION 4

What is the differential diagnosis now?

QUESTION 5

What are the risks associated with a manic episode?

QUESTION 1

What is your differential diagnosis for Adam’s presentation?

QUESTION 2

What are some of the risks associated with Adam’s symptoms?

QUESTION 3

How would you assess Adam’s risk of suicide?

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 inthe 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.


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check Bipolar disordersCASE 1

QUESTION 9

What features of depression might suggest a risk of bipolar disorder?

QUESTION 10

Describe your initial and ongoing management of Adam.

CASE 1 ANSWERS

ANSWER 1

The differential diagnosis in Adam’s 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 Adam’s 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

QUESTION 6

What advice will you give to Caity? How will you manage this

situation?

FURTHER HISTORY

Adam was taken to hospital under the Mental Health Act

after being assessed by the on call psychiatry team. He spent3 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 doesn’t think

anything was ever wrong, he has been taking his medication.

QUESTION 7

Does Adam have bipolar disorder?

QUESTION 8

What is the typical first presentation of bipolar disorder?


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• occupational problems possibly leading to unemployment

• financial problems.

ANSWER 3

Assessing risk of suicide in depression includes the following.

• Ask questions about suicidal intent:

– Have you had thoughts of wanting to die?

– Have you had thoughts of wanting to end your life?

– How often and how persistent are these thoughts?

– How long have you had these thoughts?

– Do you have a plan (eg. method, time, and place)?

– What has stopped you acting on them?

– What hopes and plans do you have for the future?

• Assess access to means of suicide

• Obtain a collaborative history to elicit indirect statements of intent to

suicide such as giving away possessions

• Obtain history on:

– past suicidal attempts and the seriousness of these attempts

– personal and social strengths and supports

– adverse life events (eg. unemployment, death of a loved one,

separation, divorce, childhood abuse)

– family history of suicide

– past history of psychiatric illness

– concurrent substance abuse or addictive behaviour

– concurrent chronic medical ill health

• Keep in mind other factors such as age, gender, place of residence,

occupation, ethnicity, marital status and sexual orientation can

influence the propensity to suicide.

ANSWER 4

The differential diagnosis now includes:

• substance-induced mania or psychosis (eg. due to antidepressant use

or illicit drugs)

• bipolar disorder – either a manic episode or a mixed episode

• a psychotic disorder (eg. schizophrenia)

• mania or psychosis due to a medical condition.

Note that antidepressants often have activating side effects such as

impaired sleep and agitation but these are distinct from antidepressant-

induced mania, and usually settle within the first few weeks of treatment.

ANSWER 5

Potential risks associated with a manic episode include:2

• risk taking behaviour resulting from a belief that one is invulnerable

• excessive spending

• alcohol or substance use and the risks associated with intoxication

(people with psychiatric symptoms often ‘self medicate’ with drugs or

alcohol)

• irritability, aggression and socially disruptive behaviour

• disinhibited behaviour such as uncharacteristic sexual activity,

including the associated risks (eg. sexually transmitted infection)• inappropriate behaviour (eg. being sarcastic, rude, aggressive) that

can damage reputation

• risks related to a potential undiagnosed medical condition (eg.

cerebral neoplasm, HIV infection).

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 psychiatricteam (see Resources – on call services are available in most

metropolitan areas of Australia).

Advice to Caity could include:

• explaining what might be causing Adam’s behaviour (eg. mania,

drugs, medication) but importantly that further evaluation is needed

in order to be able to determine the cause of Adam’s symptoms and

initiate appropriate treatment

• emergency contingency management, for instance, if Caity feels that

Adam’s symptoms or behaviour are placing her or someone else at

immediate risk of harm, she should contact the police

Table 1. Differential diagnoses of depression1

Psychiatric conditions

• Mood disorders (eg. major depressive disorder, bipolar disorder,

dysthymic disorder)

• Adjustment disorder

• Personality disorder

• Anxiety disorders (eg. obsessive compulsive disorder, post-traumatic

stress disorder, panic disorder, phobias)

• Eating disorders

• Drug and/or alcohol abuse or dependence

• Drug intoxication or withdrawal

Organic/medical conditions

• Metabolic and endocrine conditions (eg. thyroid and glucocorticoid

disturbances)

• Infection, postinfective states

• Nutritional deficiency (eg. vitamin B12, folate)

• Anaemia

• Malignancy

• Neurological disease (eg. demyelinating conditions, focal CNS disease)

• Sleep related disorders, especially sleep apnoea

Normal life stressors

• Bereavement (which can be normal or pathological)

• Other psychosocial stressors

Modified and reproduced with permission from McGraw-Hill Australia


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6

• explanation that while it would be ideal if Adam agreed to treatment,

according to state and territory law, there are situations in which

people can be assessed and treated when they don’t think they

need help (see Resources for links to state and territory mental

health acts).

Supporting Caity and her situation is important. Balancingconfidentiality with potential risks in such cases, especially if Adam

were to refuse assessment or referral, can be challenging. The Royal

Australian and New Zealand College of Psychiatrist’s Code of Ethics

provides some guidelines on maintaining confidentiality – these

guidelines apply to GPs as well as psychiatrists (see Resources ).

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. An episode of antidepressant-induced mania is thought to be part

of a bipolar disorder ‘spectrum’.5 Adam is at an increased risk of

spontaneous manic or hypomanic episodes compared to the general

population, and would be at risk of a recurrent manic episode or

rapid cycling if he were again prescribed an antidepressant without a

concurrent mood stabiliser.

A DSM-IV-TR diagnosis of bipolar I disorder requires at least one

manic or mixed episode. A mixed episode is characterised by a

period of time (lasting at least 1 week) in which the criteria are met

both for a manic episode and for a major depressive episode. The

criteria outlined in DSM-IV-TR relating to diagnosing a manic episode

and diagnosing a hypomanic episode are presented below.Criteria for diagnosing a manic episode4

• A distinct period of abnormally and persistently elevated, expansive,

or irritable mood, lasting at least 1 week (or any duration if

hospitalisation is necessary)

• During the period of mood disturbance, three (or more) of the

following symptoms have persisted (four if the mood is only irritable)

and have been present to a significant degree:

– inflated self esteem or grandiosity

– decreased need for sleep (eg. feels rested after only 3 hours of

sleep)

– more talkative than usual or pressure to keep talking– flight of ideas or subjective experience that thoughts are racing

– distractibility (ie. attention too easily drawn to unimportant or

irrelevant external stimuli)

– increase in goal-directed activity (either socially, at work or school,

or sexually) or psychomotor agitation

– excessive involvement in pleasurable activities that have a high

potential for adverse consequences (eg. engaging in unrestrained

buying sprees, sexual indiscretions, or foolish business

investments)

• The symptoms do not meet criteria for a mixed episode

• The mood disturbance is sufficiently severe to cause marked

impairment in occupational functioning or in usual social activities or

relationships with others, or to necessitate hospitalisation to prevent

harm to self or others, or there are psychotic features

• The symptoms are not due to the direct physiological effects of asubstance (eg. a drug of abuse, a medication, or other treatment) or a

general medical condition (eg. hyperthyroidism).

Note: manic-like episodes that are clearly caused by somatic

antidepressant treatment (eg. medication, electroconvulsive therapy, light

therapy) should not count toward a diagnosis of bipolar I disorder. 4

Criteria for diagnosing a hypomanic episode4

• A distinct period of persistently elevated, expansive, or irritable mood,

lasting throughout at least 4 days, that is clearly different from the usual

nondepressed mood

• During the period of mood disturbance, three (or more) of the following

symptoms have persisted (four if the mood is only irritable) and havebeen present to a significant degree:

– inflated self esteem or grandiosity

– decreased need for sleep (eg. feels rested after only 3 hours of sleep)

– more talkative than usual or pressure to keep talking

– flight of ideas or subjective experience that thoughts are racing

– distractibility (ie. attention too easily drawn to unimportant or

irrelevant external stimuli)

– increase in goal-directed activity (either socially, at work or school, or

sexually) or psychomotor agitation

– excessive involvement in pleasurable activities that have a high

potential for adverse consequences (eg. engaging in unrestrainedbuying sprees, sexual indiscretions, or foolish business investments)

• The episode is associated with an unequivocal change in functioning

that is uncharacteristic of the person when not symptomatic

• The disturbance in mood and the change in functioning are observable

by others

• The episode is not severe enough to cause marked impairment in social

or occupational functioning, or to necessitate hospitalisation, and there

are no psychotic features

• The symptoms are not due to the direct physiological effects of a

substance (eg. a drug of abuse, a medication, or other treatment) or a

general medical condition (eg. hyperthyroidism).

Note: hypomanic-like episodes that are clearly caused by somatic

antidepressant treatment (eg. medication, electroconvulsive therapy, light

therapy) should not count toward a diagnosis of bipolar II disorder.4

Presented below are some of the questions that Blackdog website provides

that can be asked of patients to ascertain whether they may have had

symptoms of hypomania (see Resources ).

• Do you have times when your mood ‘cycles’, ie. Do you experience ‘ups’

as well as ‘downs’?

• During the ‘ups’ do you feel more ‘wired’ and ‘hyper’ than you would

experience during times of normal happiness?


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7

• If yes to the above question. During these ‘up’ times, do you:

– Feel more confident and capable?

– Feel very creative with lots of ideas and plans?

– Spend or wish to spend significant amounts of money?

– Work harder and are more motivated?

– Feel irritated?

– Have an increased interest in sex?

– Talk over people?

– Do fairly outrageous things?

– Sleep less and not feel tried?

– 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. Onestudy 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 apsychiatrist 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 patient’s history

• irritable

• psychomotor retardation or agitation

• loaded family history

• abrupt onset or termination of depressive bouts

• seasonal or postpartum pattern

• hyperphagia and hypersomnia

• early age at depression onset

• delusions, hallucinations or other psychotic features.

These features are a flag of possible bipolarity in:

• depressed patients in whom past history of hypomanic or manic

episodes is ambiguous

• depressed patients with a family history of bipolar disorder

• young patients with recurrent depressive episodes.

These features are not perfectly sensitive, as illustrated by Adam’s case,

and it is unlikely that they have sufficient specificity to make a diagnosis

of bipolar disorder in the absence of other features, but they should

raise the vigilance of the treating clinician.6

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 Adam’s comorbidities

• ensuring Adam understands the risks of marijuana use

• monitoring Adam’s 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

lipids12–14

• 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.


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CASE 2 check Bipolar disorders

QUESTION 2

What is your differential diagnosis?

QUESTION 3

What are the symptoms and signs of mania and hypomania? What

factors distinguish mania from hypomania?

QUESTION 4

What investigations should be done?

QUESTION 1

Is menopause associated with depression?

FURTHER HISTORY

About 10 months ago, Sue had a 4 month period of pervasivelow 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 didn’t complete any of them. Bill had

commented that she didn’t stop talking which contrasted to

her usual somewhat taciturn state. These symptoms resolveda 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 doesn’t use drugs or alcohol.

CASE 2

SUE COMPLAINS OF DEPRESSION AND

IRRITABILITY

Sue is 52 years of age with a past history of

hypercholesterolaemia, hypertension and obesity(BMI: 31 kg/m2).

She presents complaining that her par tner of 10

years, Bill, has recently moved out because he has

found her too irritable to live with over the last 6

months. Before this, Sue felt ‘depressed’ for a while.

She stopped menstruating 1 year ago. Sue asks if

her mood changes might be related to menopause.


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QUESTION 8

What is the main source of disability in bipolar disorder?

QUESTION 9

Sue asks for more information. What resources can you refer her to?

QUESTION 10

Sue tells you that she had CBT once, but it didn’t 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 5

Does Sue need further assessment by a psychiatrist? When should a

GP refer a patient with suspected or established bipolar disorder?

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 6

How do people with bipolar II disorder typically present?

QUESTION 7

Is bipolar II disorder less severe than bipolar I disorder?


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QUESTION 13

Should hormone replacement therapy (HRT) be considered for Sue’s

affective symptoms?

CASE 2 ANSWERS

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

In situations where overlapping symptoms make it difficult to make

a definitive diagnosis of a major depressive episode, it is generally

thought that it is best to have a low threshold for a diagnosis

of major depression and a trial of treatment. In Sue’s case, her

menopausal symptoms may also need treatment.

QUESTION 11

What ongoing monitoring is required once serum lithium levels are

stable? What are the symptoms and signs of toxicity?

QUESTION 12

What might happen if Sue abruptly stopped taking lithium?

Figure 1. Changes associated with menopause and depression, with overlap shown.16 Adapted and reproduced with permission from Physicians Postgraduate Press

Menstrual irregularity, amenorrhoea

Vasomotor disturbance

(hot flushes, diaphoresis)

Vaginal atrophy and dryness

Osteoporosis

Fatigue

Poor concentration

Insomnia

Weight change (usually gain in menopause)

Irritability

Libido change

Low mood

Irritability

Anhedonia

Suicidality

Feelings of worthlessness

Psychomotor agitation/retardation

Depression Menopause

Changes associated with menopause and depression


12/2911


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

hypomanic episode is of shorter duration than a manic episode (at

least 4 days compared to 7 days), and is not associated with marked

impairment in functioning.4 Note that mood must be persistently

elevated for at least several days on end.3,4 Case 1, Answer 6 outlines

the differences between mania and hypomania.

ANSWER 4

Full blood count, electrolytes, urea, creatinine, liver function and

thyroid function tests should be done to screen for medical conditions

that might cause or exacerbate symptoms, and to assess baseline

results before considering pharmacotherapy. Fasting lipids and fasting

glucose should also be done as a baseline before consideration of

pharmacotherapy. In some cases further investigations might be

required (eg. computerised tomography, magnetic resonance imaging

[MRI] or an electroencephalogram).17

Continued monitoring of serum glucose, lipids, weight, waist

circumference/waist-hip ratio, blood pressure, and smoking status are

indicated. These should be monitored regularly in any patient at risk.For patients on psychotropic medications, monitoring of metabolic

and cardiovascular risk factors should as a minimum take place at

baseline, 3 months, and 6 months. If there have been no changes over

12 months and there are no other risk factors, monitoring can occur

every 12 months thereafter. Monitoring should be more frequent after

commencement of new medication, changes in medication, or if there

are other metabolic or cardiovascular risk factors such as weight gain

or a family history of diabetes. Sue should also have a routine breast

screen and Pap smear if these have not been done within the last

2 years.

As well as this Sue will also need a thorough physical examination.

ANSWER 5

When to refer to a psychiatrist or public mental health service depends

greatly on a patient’s presentation, the GP’s experience, the support

available from psychiatric services, and the patient’s preference. In

Sue’s case, as this is her first presentation of symptoms suggestive

of possible bipolar disorder, referral to a psychiatrist is recommended.

Some reasons for referral from the National Institute for Health and

Clinical Excellence (NICE) guidelines in the United Kingdom are shown

in Table 3 .

ANSWER 6

People with bipolar II disorder usually seek help only for depressiveepisodes. This is probably in part because hypomanic episodes

are often not perceived by the patient as abnormal. Patients may

experience mood elevation as constructive and enjoyable.6,18

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

Table 2. Signs and symptoms of hypomania and mania

include the following types of behaviour which are out

of character for the individual6

• Feeling energised and ‘wired’

• Inflated sense of self importance or of one’s abilities

• Excessively seeking stimulation

• Overly driven in pursuit of goals

• Needing less sleep

• Irritable if stopped from carrying out ideas

• Disinhibited and flirtatious

• Offensive or insensitive to the needs of others

• Swearing more than usual

• Spending money in an unusual manner or inappropriately

• Indiscrete and disregarding social boundaries

• Poor self regulation

• Making excessively creative and grandiose plans

• Difficulty discussing ideas rationally or maturely

• Reporting enhanced sensory experiences

Reproduced with permission from The Medical Journal of Australia


13/2912


bipolar I (ie. patients tend to have a greater total number of

episodes). Furthermore, bipolar II disorder is associated with

increased morbidity if it becomes chronic, is undiagnosed or

inappropriately treated.19

ANSWER 8

Depression is the main source of disability in bipolar I and II.

Depressive symptoms typically affect up to 30–50% of the patient’s

life, while manic symptoms affect about 5–10%.18

ANSWER 9

The Resources section lists a number of useful sources of information

that can help patients as well as practitioners. It is helpful to ask patients

what they have looked up and actively discuss this with them. 20

ANSWER 10

Psychological treatments help reduce the risk of relapse and can

therefore be helpful even to euthymic patients. While CBT is an effective

treatment in many patients with bipolar disorder, particular approaches

don’t suit some patients. So in Sue’s situation, she may wish to try

other psychological strategies. Possibilities for Sue include:10

• further psychoeducation

• interpersonal and social rhythm therapy

• couples therapy (if she reunites with her partner)

• group therapy.

It is useful to ask patients to describe any psychological interventions

they have had in the past, and what aspects of these they

found helpful. Some patients appreciate being told about the

characteristics of different modalities as well as the potential benefitsand risks so that they can make an informed decision about what

type of treatment they would like to engage in.

ANSWER 11

Sue should be informed of the symptoms and signs of lithium

toxicity.

The appropriate pretreatment tests include thyroid and renal

function, serum calcium and electrocardiogram.

Monitoring of lithium treatment should include:

• serum lithium level every 3–6 months once a stable level is

achieved (aim for 0.6–0.8 mmol/L for maintenance therapy)12,17

• serum urea and creatinine every 3–6 months

• thyroid stimulating hormone, serum calcium, weight at 6 months

then annually.

Lithium can cause hypothyroidism and hyper thyroidism,

hyperparathyroidism, and renal impairment.12,22

Lithium toxicity can cause:

• ataxia

• nausea/vomiting

• diarrhoea

• coarse tremor

• disorientation

• dysarthria

• muscle twitches

• impaired consciousness

• acute renal failure

• even death.22

ANSWER 12

There is a risk of rebound mania if lithium is ceased abruptly.

ANSWER 13

Although there may be an increased risk of depressive symptoms

around the time of menopause, and sex hormones may play a role in

the pathophysiology of some psychiatric disorders, there is currently

no clear evidence for the benefit of HRT on these symptoms.15

Pharmacological treatment of psychiatric illness should be managed

in the same way as it would in any other patient. Similarly, decisions

about prescribing HRT should be made as they would be for women

without psychiatric illness. There are circumstances in which HRT

may have a role in the treatment of psychiatric symptoms, but

decisions on this are limited to specialist practice.

Table 3. Some reasons for referral21

• Primary care clinicians should urgently refer to specialist mental health

services, patients with mania or severe depression who are a danger to

themselves or other people

• When a patient with existing bipolar disorder registers with a practice,

the GP should consider referring them for assessment by a psychiatrist

or specialist mental health service

• When a patient with bipolar disorder is managed solely in primary care,

an urgent referral should be made:

– if there is an acute exacerbation of symptoms, in particular the

development of mania or severe depression

– if there is an increase in the degree of risk, or change in the nature of

risk, to self or others

– if there are psychotic symptoms

• When a patient with bipolar disorder is managed solely in primary care, a

review by a psychiatrist/public mental health service or increased contact

in primary care should be considered if:

– the patient’s functioning declines significantly or their condition

responds poorly to treatment

– treatment adherence is a problem– comorbid alcohol and/or drug misuse is suspected

– the patient is considering stopping prophylactic medication after a

period of relatively stable mood

• Specialist treatment is usually required in cases with comorbid

psychiatric conditions, mixed episodes or rapid cycling, and where there

is failure to respond to treatment

• Specialist input will also be needed in new diagnoses, if there is

uncertainty regarding the diagnosis and may be needed in cases with

significant medical comorbidity

Adapted and reproduced with permission from The Royal College of

Psychiatrists, London


14/2913


QUESTION 3

How would you clarify Sally’s diagnosis?

QUESTION 4

Sally’s father has bipolar disorder. How does this affect her risk of

developing bipolar disorder?

FURTHER INFORMATION

After Sally’s 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 6–8 standard drinks every

other day. She also thinks she might be pregnant.

QUESTION 5

List some of the aspects of Sally’s physical health which you need

to address.

QUESTION 1

What is your differential diagnosis for Sally’s presentation?

QUESTION 2

Could cannabis do this? What effects does cannabis have on mood?

CASE 3

SALLY HASN’T BEEN HER USUAL SELF

Sally, 23 years of age, is a single university student.

She recently moved out of home and is living

with a flatmate. She was taken to the emergencydepartment by friends after she cut her foot on

some glass at a nightclub.

Sally’s friends say they have been worried because

she has been:

• excessively social over the past month

• neglecting her studies

• bringing men home for sex (she is usually very shy)

• spending excessive amounts of money

• getting very little sleep

• very angry when it was suggested she ‘slow down’.

Sally is skimpily clad in bright, revealing clothes,

with garish makeup. She is coquettish and has

pressured speech. She says that she has been

feeling very depressed, so has been smoking

cannabis daily and has used intravenous

amphetamines twice in the last month. Her father

has bipolar disorder.


15/2914


QUESTION 9

If Sally was not pregnant what approaches could you use to treat

Sally’s depression?

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.

ANSWER 2

Acutely, one of the most character istic ef fects 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 Sally’s 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.

QUESTION 6

What are the problems associated with sodium valproate in this

patient? What other medication strategies might you consider?

QUESTION 7

How would you address Sally’s ongoing substance use?

QUESTION 8

What are the stages of behavioural change? How would you

structure the questions you ask about a patient’s stage of change?

What intervention would you consider for each stage?


16/2915


ANSWER 3

Sally’s 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 5–10 times that

of the general population.26

ANSWER 5

The following aspects of Sally’s physical health need to be

addressed.

• Pregnancy testing and contraception – given that many

pregnancies are unplanned, it is important to discuss thepossibility 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 forPCR – 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 Sally’s 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 1–5% 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

Table 4. Substance-induced symptoms28

Substance-induced symptoms can result from intoxication,

chronic use or withdrawal

• Intoxication with cannabis can produce a transient, self limiting psychotic

disorder characterised by hallucinations and agitation

• Prolonged heavy use of psychostimulants (eg. amphetamine,methylenedioxymethamphetamine [MDMA]) can produce a psychotic

picture

• Hallucinogen induced psychosis is usually transient, but may persist if use

is sustained

• Heavy alcohol use can be associated with alcoholic hallucinosis and

morbid jealousy

• Psychotic symptoms can also occur during withdrawal (eg. delirium

tremens) and delirious states

• A nonsubstance-induced disorder should be considered when:

– symptoms precede the onset of substance use

– symptoms persist for longer than 1 month after acute withdrawal or

severe intoxication

– symptoms are not consistent with the substance used

– there is a history of symptoms during periods

(greater than 1 month) of abstinence

– there is a personal or family history of a nonsubstance-induced

psychiatric disorder

Adapted and reproduced with permission from The Medical Journal o f Australia

than lithium or anticonvulsants, although there is inadequate data

for many agents. There is inadequate data available for second

generation antipsychotics, although gestational diabetes has been

associated with olanzapine. Lithium is associated with a risk of

Ebstein abnormality of about 1 in 1000, compared to the general

population rate of 1 in 20 000. Carbamazepine carries a risk of

neural tube defects of about 1%. It is also associated with facial

malformations, and developmental delay.27

Women with a history of bipolar disorder are particularly vulnerable

during pregnancy and the postpartum. Untreated bipolar disorder puts

both the mother and foetus at risk, but at the same time all psychotropic

drugs have the potential to affect the foetus.

The management of bipolar disorder during pregnancy is best decided

on a case-by-case basis after evaluation of the risk/benefit ratio for

each individual.

Bipolar disorder in pregnancy requires specialist (psychiatric)

management in collaboration with the GP, obstretrician, midwife and

psychological care.

ANSWER 7

Addressing Sally’s ongoing substance abuse involves establishing

rapport and a good therapeutic alliance, educating her about the

effects of her substance use and its link to her current psychological

symptoms, treating her mood disorder, assessing her motivation for

change, referral to the appropriate services, discussing triggers for

relapse and discussing relapse prevention. Table 5 lists these principles

of management for a GP involved in the care of a patient with ongoing

substance use.


17/2916


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 makingin each of these stages. The type of intervention varies depending on

the stage of Sally’s 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 Sally’s depression include the following.

• Dealing with Sally’s 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 supportivepsychotherapy, 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 1–2 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.

Table 5. Principles of management of patients with

comorbid substance misuse28

• First engage patients, adopting a nonjudgmental attitude

• Educate the patient:

– give general advice about harmful effects of substance misuse

– advise about safe and responsible levels of substance use

(eg. National Health and Medical Research Council guidelines for safe

alcohol use)

– help the patient understand and appreciate links between substance

misuse and symptoms (eg. cannabis use and mood changes)

– inform the patient about safe practices (eg. using clean needles, not

injecting alone, practicing ‘safe sex’)

• Treat mood disorder and monitor the patient for potential side effects

• Help the patient establish advantages and disadvantages of current use,

and motivate the patient for change

• Evaluate the need for concurrent substance-use medications

(eg. methadone, acamprosate, nicotine replacement therapy)

• Refer the patient to relevant clinical and community services asappropriate

• Devise relapse prevention strategies that address both mental illness and

substance misuse

• Identify triggers to relapse (eg. meeting other drug users, being paid,

family conflict) and explore alternative coping strategies. It is important to

identify triggers for both substance use and mood episodes, and to show

links between these where they exist

Adapted and reproduced with permission from The Medica l Journa l of Austra lia


18/2917


Table 6. Stages of change and interventions28,29

Stage of change Characteristics Questions to the patient Intervention

Precontemplation

Goal: patient to begin

thinking about change

• Not thinking about change

• May be resigned

• Feeling of no control

• Denial – does not believe it applies

to self

• Believes consequences are not

serious

• What warning signs would let you know

that this is a problem?

• How will you know when it is time to quit?

• Have you tried to change in the past?

• Educate patient about substance

misuse

• Help the patient to examine problems

with their current behaviour

Contemplation

Goal: patient to examine

benefits and barriers to

change

• Weighing benefits and costs of

behaviour and proposed change

• Why do you want to change at this time?

• What were the reasons for not changing?

• What are the barriers today that keep you

from change?

• What might help you with those aspects?

• What things (eg. people, programs and

behaviours) have helped in the past?

• What would help you at this time?

• Explore ‘pros and cons’ of change

• Acknowledge patient’s ambivalence

and resistance to change

Preparation • Experimenting with small changes • Have you tried doing anything differently?

• What do you think has been helpful, or

unhelpful?

• Are there other things that you would be

interested in trying, or hearing about?

• What has worked in the past? Would you

like to try this again?

• Would you like to discuss some of the

other options available (eg. psychological

treatments, medications, programs)?

• Help patient to determine the most

appropriate strategies for change

Action • Taking a definitive action to change • Do you have any questions about this

action?

• How have things been going with this

action?

• What aspect of this action have you found

most effective?

• Assist patient to instigate planned

changes

Maintenance • Maintaining new behaviour over

time

• Could you tell me about some prevention

strategies you’ve learned?

• Have there been any times where you were

close to using again?

•

Could we talk about ways of dealing withthese times should they arise again?

• What strategies are working well? Maybe

you could write these down so that you can

remember them in case you have a lapse.

• Encourage new skills

• Rehearse relapse revention strategies

Relapse • A normal part of the process of

change

• Usually feels demoralised

• (A lapse is very common. In fact, most

people who eventually recover from drug

or alcohol use lapse at least once.) How do

you feel about your use now?

• Support patient

• Assist in renewing process of change


19/2918


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?

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, Samcomplains of poor sleep. As Sam’s 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 can’t 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 betweenbipolar disorder and ADHD?

QUESTION 1

What is your differential diagnosis for Sam’s presentation?

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, can’t 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.

Sam lost his job due to altercations with his

colleagues and boss, and broke up with hisgirlfriend of 6 months shortly afterwards.

Further questioning reveals longstanding episodes

of irritability of mood. Similar to the current episode,

these are characterised by sustained irritability,

hyperactivity, overspending, and a decreased need

for sleep. These symptoms last for weeks and

are followed by depression, which lasts weeks to

months.

He has a background of longstanding alcohol use

and increasing use of intranasal speed which ‘helps

mood and concentration’.

He never really got on with others at school anddropped out at age 15. He describes himself as ‘just

hopeless’ at academic work.

He has had warnings for domestic violence and pub

fights, and lost his driver’s licence for speeding.


20/2919


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?

CASE 4 ANSWERS

ANSWER 1

The differential diagnosis is:

• major depression with irritability

• anxiety disorder

• substance-induced mood disturbance

• bipolar disorder (mixed episode)

• adjustment disorder

• 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.

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?

QUESTION 5

What is the relationship between bipolar disorder and ADHD in

adults?

QUESTION 6

What further treatment options might you consider and what are the

risks and benefits?


21/2920


of childhood ADHD must be obtained, beginning with a good

developmental history. Reviewing Sam’s school records and

interviewing his parents would be helpful.

A rating scale may also help (eg. Wender Utah Rating Scale,32 Conners

Adult ADHD Rating Scale33 ).

It is important to confirm that ongoing inattentiveness and hyperactivityhas occurred in the absence of drug use.

ANSWER 5

There is little research in this area, and it is unclear what relationship

(if any) exists between ADHD and bipolar disorder.35 Nonetheless

some epidemiological evidence suggests that they do co-occur more

commonly than would be expected by chance. One study showed a

lifetime prevalence of ADHD of 9.5% in people with bipolar disorder.36

ANSWER 6

Sam can be provided with details of available stimulants. The potential

risk of a manic switch with stimulants should be discussed (although

this would be lower if he was also on a mood stabiliser).

Some general management tips for people with comorbid ADHD and

bipolar disorder are listed in Table 9 .

Information about medications for ADHD can be found in the Australian

Medicines Handbook 37 and Therapeutic Guidelines .22

ANSWER 7

Little research has been carried out on psychosocial treatment of

ADHD in adults. Residual symptoms in people on pharmacotherapy are

common, and CBT-based approaches that target deficits in planning,

organisation and attention, and include psychoeducation may help.38

Psychological treatments for Sam’s drug and alcohol comorbidities

should also be implemented (eg. motivational interviewing,39 as well as

psychological treatments aimed at bipolar disorder).10

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 4The 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

Table 7. Diagnostic symptoms of a manic episode and

ADHD34

Manic episode ADHD Degree of overlap

Psychomotor agitation Hyperactivity Extensive

Impulsive Impulsivity ExtensiveDistractibility Inattention Extensive

Irritability Ubiquitous Extensive

More talkative Talks too fast Moderate

Elation – Little

Grandiosity – Little

Flight of ideas/racing thoughts – Little

Decreased need for sleep Dif ficulty set tl ing

for sleep

Little

Increased goal-directed activity – Little

Excessive pleasurable activities

(eg. hypersexuality)

– Little

Reproduced with permission from Springer

Table 8. Diagnostic symptoms of bipolar depression

and ADHD34

Bipolar depression ADHD Degree of

overlap

Depressed mood Dysphoria Extensive

Insomnia Difficulty settling Extensive

Irritability Irritability Extensive

Difficulty concentrating Inattention Extensive

Psychomotor agitation Hyperactivity Moderate

Disinhibition Impulsivity Moderate

Weight loss/gain Weight loss with

stimulants

Moderate (after

stimulant treatment)

Psychomotor retardation – Little

Fatigue or loss of energy – Little

Hypersomnia – Little

Loss of interest or pleasure – Little

Thoughts of death/suicidality – Little


Table 9. The sequential initiation of treatment for

patients with bipolar disorder and concurrent ADHD34

• Remove the offending agent

– stimulants (if you cannot completely discontinue, try for ‘drug

holidays’ – short breaks)

– antidepressants

– benzodiazepines

• Maximise antimanic treatments

– use adequate blood levels and doses

• Attempt to reintroduce the stimulant only after the mood is stabilised and

it has been demonstrated that such treatments continue to be indicated.

If you cannot wait, remember that it is likely to delay the treatment

response time for the antimanic

• Try to ‘kill two birds with one stone’ when possible (eg. use agents that

may improve more than one pole of bipolar disorder)

• Consider discontinuation of stimulants periodically



22/2921


QUESTION 2

Is it possible that Mrs Smith has dementia? How could you tell?

QUESTION 1

What is the differential diagnosis for Mrs Smith’s presentation? What

is the most likely diagnosis?

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 low-level 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 showedmild 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 low-

level 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

commenced on lithium but ceased taking this after

discharge.

She is currently taking lithium 500 mg twice per day as well

as paracetamol 1 g four times per day and celecoxib 100

mg twice per day, which were commenced 3 weeks ago for

osteoarthritic pain. There is no other known medical history.

Over the past 2 weeks, Mrs Smith hasn’t been eating much

and has been spending much of the day lying in bed. The

nursing staff think she has lost some weight. She has been

seen wandering the halls at night on a few occasions. She is

agitated and seems confused. On one occasion she asked the

staff, “Are the Russians here yet?” One of the nurses thinks

Mrs Smith has been seeing things.

You are asked by staff if you think she is depressed. You

examine Mrs Smith.

She is confused and able to provide only a limited account of

things but says that she feels nauseated and has had somediarrhoea.

An MMSE is 12/30:

• not oriented to time or place

• scores 0/5 for serial 7s

• 0/3 for three item recall.

Heart rate, respiratory rate, blood pressure, temperature and

oxygen saturation are within normal limits. She has a coarse

tremor of her hands. Oral mucosa is mildly dry. There are

osteoarthritic changes in her upper and lower limbs. Pinprick

blood sugar is 5.1 mmol/L. Otherwise, cardiovascular,

gastrointestinal, respiratory, and neurological examinationsare normal. A serum lithium level is 1.5 mmol/L; urea,

electrolytes and creatinine are normal.


23/2922


CASE 5 ANSWERS

ANSWER 1

Differential diagnoses in this scenario include delirium, dementia and

depression. Delirium secondary to lithium toxicity is the most likelycause of this presentation. Note that delirium is often misdiagnosed

as depression.40–42 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

It is essential to consider delirium in differential diagnosis in an

elderly person who is presenting with emotional, cognitive, orbehavioural symptoms, especially if they are of abrupt onset.

ANSWER 2

The clinical distinction between delirium and dementia can be

complicated.

Dementia is the main risk factor for delirium. Two-thirds of cases of

delirium occur in patients with dementia.40 It would be reasonable

to consider the possibility of underlying dementia once the cause

of Mrs Smith’s delirium has been treated, but dementia would not

account for her acute change ( Table 10 ).

Delirium is common and is frequently missed. It is an important

nonspecific sign that often heralds the development of a life

threatening illness. It includes the following features.

• It typically has an acute onset and tends to fluctuate, and is often

worse at night

• Inattention and sleep-wake cycle disturbances – these may be the

most frequent findings41

• Other common features include a disturbance of consciousness,

cognitive impairment, perceptual disturbance, disorganised

thinking, emotional/behavioural disturbances

• Orientation alone is an insufficient screening test, this may be the

least frequent cognitive deficit.41

QUESTION 3

What is your short term management plan?

QUESTION 4

Over the longer term, what monitoring and follow up should Mrs

Smith have?

QUESTION 5

Are psychological treatments for bipolar disorder indicated in the

elderly? Would these be helpful for Mrs Smith?

Table 10. Clinical features of delirium verses dementia

Feature Delirium Dementia

Onset Rapid Insidious

Primary deficit Attention Short term memory

Course Fluctuating Progressive

Duration Days to weeks Months to years

Consciousness Clouded Clear

CASE 5


24/2923


• recommended lithium ranges for acute mania are usually

0.8–1.2 mmol/L. Lower ranges (eg. 0.6–0.8 mmol/L) are

recommended for maintenance treatment. Toxicity occurs at

levels >1.5 mmol/L, but can occur at ‘therapeutic levels’ in the

elderly. Levels >3.5 mmol/L are potentially lethal.22 There is not

much data upon which to guide serum levels in older adults, but

levels of 0.5–0.8 mmol/L are often recommended.17

Over the longer term, monitor for cognitive decline (Mrs Smith had

some mild deficits when neuropsychological testing was done in her

first hospitalisation).

Assessment for vascular risk factors:

• monitor blood pressure

• check fasting lipids

• monitor weight, waist circumference, waist to hip ratio and BMI

• Mrs Smith’s recent blood sugar level was normal, but you should

consider checking this again in the future.

Mrs Smith should also be monitored for signs and symptoms ofmajor depression or mania.

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 Smith’s current state, psychologicalinterventions (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

There are hyperactive and hypoactive forms of delerium. The

hypoactive form is more common in the elderly, and is often

missed. Mild states are also often missed, especially by those not

familiar with the patient’s usual intellectual performance. Differential

diagnoses include dementia and mood disorders, especially

depression (delirium is often misdiagnosed as depression).40–42

Almost any physical illness can give rise to delirium in the elderly.

Common causes include medications, infections, metabolic and

endocrine derangement, cardiovascular disease, respiratory

disease, intracranial pathology, gastrointestinal disease, metabolic

derangement, and alcohol withdrawal. A broad differential diagnosis

should be considered, and a thorough physical examination is

essential.

Some common misunderstandings about delirium are listed in

Table 11.

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 4

Regular monitoring of lithium levels, renal function, and thyroid

function should be undertaken:

• creatinine clearance can decrease with age, affecting serum

lithium levels

Table 11. Common misunderstandings about delirium41

• The typical presentation is of delirium tremens (ie. agitated, floridlypsychotic)

• More severe delirium is associated with a greater degree of hyperactivity

• Quiet and well behaved patients are generally cognitively intact

• Older people are normally forgetful and easily disoriented

• Irritability or vagueness often reflects personality rather than an altered

mental state

• Patients are offended by tests of cognition

• A patient’s level of orientation and cognitive function are consistent over

24 hours

• Delirium rarely responds to treatment in those with underlying advanced

disease

Modified and reproduced with permission from The Royal College ofPsychiatrists, London

CASE 5


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1. Murtagh JE. General practice. 3rd edn. Sydney: McGraw Hill,

180–188.

2. Bassett DL. Risk assessment and management in bipolar disorders.

MJA 2010;193:S21–S23.

3. World Health Organization. International Classification of Diseases

(ICD-10). Available at http://apps.who.int/classifications/apps/icd/

icd10online.4. American Psychiatric Association. Diagnostic and Statistical Manual

of Mental Disorders DSM- IV-TR. 4th edn. Washington, DC: American

Psychiatric Association, 2000.

5. Ghaemi SN, Ko JY, Goodwin FK. ‘Cade’s disease’ and beyond:

misdiagnosis, antidepressant use, and a proposed definition

for bipolar spectrum disorder. Canadian Journal of Psychiatry

2002;47:125–34.

6. Michell PB, Loo CK, Gould BM. Diagnosis and monitoring of bipolar

disorder in general practice. MJA 2010;193:S10–S13.

7. Hirschfeld RMA, Lewis L, Vornik LA. Perceptions and impact of

bipolar disorder: how far have we really come? Results of the National

Depressive and Manic-Depressive Association 2000 Survey of

Individuals with Bipolar Disorder. J Clin Psychiatry 2003;64:161–74.

8. Pies R. Is it bipolar depression? ‘WHIPL ASHED’ aids diagnosis.

Current Psychiatry 2007;6:80–81.

9. Piterman L, Jones KM, Castle DJ. Bipolar disorder in general

practice: challenges and opportunities. MJA 2010;193:S14–S17.

10. Lauder SD, Berk M, Castle DJ, et al. The role of psychotherapy inbipolar disorder. MJA 2010;193:S31–S35.

11. Morriss R. The early warning symptom intervention for patients

with bipolar af fective disorder. Advances in Psychiatric Treatment

2004;10:18–26.

12. Malhi GS, Adams D, Berk M. The pharmacological treatment of

bipolar disorder in primary care. MJA 2010;193:S24–S30.

13. Malhi GS, Adams D, Lampe L, et al. Clinical practice

recommendations for bipolar disorder. Acta Psychiatrica Scandinavica

2009;119(Suppl 439):27–46.

14. Conn TA, Sernyak MJ. Metabolic monitoring for patients treatedwith antipsychotic medications. Canadian Journal of Psychiatry

2006;51:492–501.

15. Dennerstein L, Alexander JL. Mood and menopause. In: Castle DJ,

Kulkarni J, Abel KM, editors. Mood and anxiety disorders in women.

Cambridge Universit y Press: Cambridge, 2006;212–241.

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):16–21.

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;38:280–305.

18. Tiller JWG, Schweitzer I. Bipolar disorder: diagnostic issues. MJA

2010;193:S5–S9.

19. Berk M, Dodd S. Bipolar II disorder: a review. Bipolar Disorders

2005;7:11–21.

20. Lam-Po-Tang J, McKay D. Dr Google, MD: a survey of mental health-

related internet use in a private practice sample. Australas Psychiatry

2010;18:130–3.

21. National Collaborating Centre for Mental Health. Bipolar disorder: themanagement 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.

22. Psychotropic Expert Group. Therapeutic Guidelines: psychotropic.

Version 6. Melbourne: Therapeutic Guidelines Limited, 2008.

23. Castle DJ, Solowij N. Acute and subacute psychomimetic effects

of cannabis in humans. In: Castle D, Murray R, editor s. Marijuana

and madness: psychiatry and neurobiology. Cambridge: Cambridge

University Press, 2004;41–53.

24. Degenhardt L, Hall W, Lynskey M, et al. The association betweencannabis use and depression: a review of the evidence. In: Castle

D, Murray R, editors. Marijuana and madness: psychiatry and

neurobiology. Cambridge: Cambridge University Press, 2004;54–74.

25. Parker G. Comorbidities in bipolar disorder: models and management.

MJA 2010;193:S18–S20.

26. Craddock N, Jones I. Molecular genetics of bipolar disorder. Br J

Psychiatry 2001;178:S128–S133.

27. Misri S, Carter D, Little RM. Bipolar affective disorder: special issues

for women. In: Castle DJ, Kulkarni J, Abel KM, editors. Mood and

anxiety disorders in women. Cambridge: Cambridge UniversityPress, 2006;185–211.

28. Lubman DI, Sundram S. Substance misuse in patients with

schizophrenia: a primary care guide.

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