managing bipolar disorder and schizophrenia in primary care dr claire littlewood consultant old age...

Managing Bipolar Disorder and Schizophrenia in Primary Care

Dr Claire LittlewoodConsultant Old Age Psychiatrist

Overview

Introduction Primary Care focus Diagnosis / classification When to refer, and who to? Treatment guidelines Primary care monitoring Prognosis and longer term management Case studies

Schizophrenia

Classification (how to understand the psychiatrist’s letter!)

ICD10 defines 4 main subtypes (+ undifferentiated /other categories)

General characteristics: psychosis i.e.. positive symptoms (delusions and hallucinations), abnormal affect/volition (negative symptoms), first rank symptoms

Cognitive deficits often develop over time

Schizophrenia diagnosis cont.

Psychosis (delusions and hallucinations) is a symptom with various aetiologies e.g..

Schizophrenia Psychotic mood disorder Dementia Delirium Alcohol / substance misuse How to distinguish?

First rank symptoms

Thought echo / insertion / withdrawal

Thought broadcasting Delusional perception Passivity Third person auditory hallucinations Strongly suggestive of

schizophrenia

Subtypes of schizophrenia, and why do we care?

Paranoid (mainly positive symptoms) Hebephrenic (mainly negative symptoms

– rapid onset) Catatonic (rare) Simple (slow onset negative symptoms,

generally not preceded by psychosis) (Schizo-affective disorder) (Paraphrenia – late onset schizophrenia)

Positive/negative symptoms

Why do we care? – because the relative presence/absence of these helps predict course/ treatment response and prognosis.

Generally – negative symptoms are harder to treat and suggest poorer prognosis

Each person with schizophrenia has their own unique combination of symptoms

Typical presentation to primary care (age 15-35)

Prodromal period – characterised by decline in personal functioning (memory, concentration, odd behaviour and/or ideas, disturbed mood, social withdrawal etc) i.e. predominantly negative symptoms

Usually followed by acute episode of positive symptoms – common point of presentation

Co-existent disorder may ppt. presentation

Depression Anxiety Substance misuse Personality disorder Substance misuse NB Schizophrenia has lifetime

prevalence of 1%

Great variation in presentation

Some have positive symptoms briefly, others for years

Some have no prodrome Some have no positive symptoms Some have just one acute episode

which responds to treatment Some have residual negative

symptoms for years which may be interspersed with acute episodes

When / where to refer

General rule - urgently refer any first (and subsequent) presentation psychotic symptoms (positive symptoms) to secondary care (unless obvious delirium)

Better prognosis if treated early Could commence anti-psychotic in

primary care if experienced Refer to CMHT (single access point)

Treatment guidelines

NICE CG82 March 2009 Schizophrenia (update)

Physical – antipsychotics Psychological (offer CBT to all and

family therapy if appropriate) – both may be started in acute phase or later

(Psychological input would be in secondary care)

Antipsychotics

Typical (older) and atypical (newer) Typicals block dopamine Atypicals block dopamine to lesser extent, and also

have effects on other neurotransmitters e.g.. 5HT – hence have some effect on negative symptoms

Efficacy same (NB Clozapine) Difference is side effect profiles (and effects on

negative symptoms) Choice made by patient and professional Good practice to do ECG first especially if cvs

risk/history

Common side effects

Typicals cause following through dopamine blockade:

Parkinsonian symptoms (block dopamine)

Akathisia Tardive dyskinesia Atypicals cause above too but to

lesser extent

Common side effects cont.

Atypicals are lore likely than typicals to cause following:

Weight gain Increased chance developing

diabetes Sexual dysfunction In higher doses, movement

disorders as for typicals

Anti-cholinergics

Used to treat parkinsonian side effects / akathisia

Good practice to reduce dose anti-psychotic first to see if side effects lessen (secondary care)

Abuse potential Cause cognitive problems in elderly Best used as prn

Tardive dyskinesia

Longer term side effect Continual movements mouth,

tongue, face 1 in 20 Best treatment is to reduce/stop

antipsychotic Anticholinergics tend to make it

worse (hypothesis of TD being related to cholinergic deficiency)

Antipsychotics cont

Avoid combinations of antipsychotics (secondary care)

If stable on typicals and tolerating etc – leave!

Issues re stelazine Withdrawal should be gradual with regular

monitoring Monitor for relapse for at least 2 years

post withdrawal (usually secondary care) Depot antipsychotics will always be

started in secondary care

Ongoing monitoring in Primary Care (after acute episode)

NICE states ‘offer people with schizophrenia whose symptoms have remained stable (on or off treatment) the option to return to primary care for further management’

NICE also states: consider re-referral to secondary care if relapse, risk, poor treatment response, non-concordance, problematic side effects, co morbid substance misuse etc

Physical health monitoring in Primary Care

Annual, with focus on CVS (higher risk CVS disease and DM than general population)

Lipid levels Plasma glucose / TSH Weight Smoking / alcohol BP

Prognosis

High risk relapse if stop meds in 1-2 yrs post acute episode

After just one episode 25% chance remission, so for most chronic course

If more than one episode and stop meds, usually recurs within 6 mnths

More negative symptoms = worse prognosis

Summary of schizophrenia

Individual presentations vary greatly

Positive (including first rank) and negative symptoms

First acute episode (largely positive symptoms) usually ppts presentation to primary care

Psychosis is a symptom with Various aetiologies

Summary cont

Typical presentation is prodrome (mainly negative symptoms) followed by acute episode (mainly positive symptoms)

Co-morbid mental health problems common

Most have a chronic course interspersed with acute episodes

Acute episodes should be managed in secondary care as should Risk, poor treatment response, non-concordance, problematic side effects, co morbid substance misuse

Summary cont

Antipsychotics mainstay treatment of acute episodes

Typicals/atypicals have same efficacy/different side effects

Psychological therapies (CBT/family) Primary care have key role in referring

acute episodes, monitoring physical health and longstanding stable schizophrenia

Negative symptoms assoc. with worse prognosis

Case study

Nigel is 19. He started at a local university 6/12 ago to do computer science, but failed to attend lectures after the first few weeks. His concentration declined, and he became more and more socially withdrawn. One day he became very agitated, stating there were hidden cameras in his bedroom spying on him.

He is diagnosed with schizophrenia by a psychiatrist

Case study cont.

Could Nigel’s schizophrenia have been identified at an earlier stage?

He responded well to risperidone, and is discharged back to primary care once stable. How long should he continue on Risperidone for? What’s his longer term prognosis?

When/why might you re-refer him?

Bipolar affective disorder

Defined (ICD10) as two or more episodes of abnormal mood – one of which must be mania/hypomania

A single manic/hypomanic episode is not bipolar

Repeated episodes (2 or more) of mania/hypomania are classified as bipolar

Hypomania

Mild elevation of mood (includes irritability)

Increased energy / activity Decreased need for sleep Pressured speech/ thought Over familiarity NOT psychotic symptoms

Mania

More extreme form of hypomania May occur with or without psychotic

symptoms (e.g.. grandiose delusions) Behaviour can be very risky e.g..

aggression, recklessness (e.g.. sexual, financial)

Significant physical risk, especially in elderly

Diagnosis for each affective episode noted e.g.

Bipolar disorder, current episode moderate depression

Bipolar disorder, current episode manic with psychotic symptoms

Bipolar disorder, current episode mixed (mixture or rapid alteration of manic and depressive symptoms)

When to refer to CMHT (NB may go to home treatment etc)

NICE CG38 Bipolar disorder Urgently refer new or suspected

cases with mania or severe depression who pose risk to self / others

Also refer patients with a 4 (or more) day history over activity / disinhibition, or a history of such activity

If existing bipolar disorder managed in primary care:

Refer urgently if relapse / risk etc Refer for review if deterioration e.g..

mood disturbance, more frequent acute episodes, co-morbid mental health issues, poor concordance etc

Consider referring a new patient with existing bipolar who registers with the practice

Other NICE points to note:

Limited evidence for treating bipolar II disorder (hypomania and not mania) (so use recommendations for bipolar I)

Term ‘mood stabiliser’ not used Antimanic drugs (antipsychotics, lithium,

valproate) Prophylactic drugs i.e.. any drugs used for

long term management (antipsychotics, lithium, valproate)

Managing acute (hypo)manic episodes (secondary care)

Consider stopping antidepressant Antipsychotic (olanzapine, risperidone or

quetiapine). If response inadequate, consider adding Li or valproate

Li or valproate may be used before antipsychotic if symptoms not severe / previous response (avoid valproate in women of child bearing age)

Manage mixed episodes as for manic

Managing acute (hypo)manic episodes in secondary care

Short term benzos may be helpful Carbamazepine not routinely used

for acute mania (if already taking, consider adding anti-psychotic)

Managing depressive episodes within bipolar disorder

Again – secondary care probably If prescribe antidepressant, need to

also consider antimanic drug and or mood stabiliser / prophylactic agent

SSRIs first line, as for unipolar depression

Psychological treatments not recommended in acute affective episodes

Long term management of bipolar

Often remain in secondary care (usually runs chronic and recurrent course – often length of acute episodes increases (and time between decreases) with increasing age

Prophylaxis: Lithium, Olanzapine or valproate (combinations may be used)

If ineffective: lamotrigine or carbamazepine Antidepressants not routinely continued long term Psychological interventions e.g. CBT are

recommended if relatively stable/ non acute

Primary care has key role in physical health monitoring

Bipolar pts have higher levels physical morbidity/mortality than general popn.

Annual Lipid levels, incl. cholesterol if over 40 yrs Plasma glucose /TSH Weight Smoking / alcohol BP

Primary care monitoring of specific drugs

Li level every 3-6/12 and U and Es /TSH every 6/12

Carbamazepine and valproate: FBC and LFTs every 6/12

Carbamazepine: U and Es every 6/12

More on lithium

Aim for 0.4-0.8 mmol/l Elderly especially prone to toxicity Levels can be affected by ACE

inhibitors, diuretics, NSAIDs Toxicity symptoms include GI upset,

tremor, ataxia,confusion,convulsions

Summary of Bipolar Affective Disorder

Defined (ICD10) as two or more episodes abnormal mood, one of which must be mania/hypomania

Hypomania is a mildly elevated mood without psychosis, mania is a more extreme elevation (+/- psychosis) and often with assoc. risky behaviour.

Summary cont.

Urgently refer to secondary care any new presentations hypomania/mania or severe depression, esp. if risks

Refer existing bipolar patients if relapse, deterioration, substance misuse etc

Drug treatment consists of antimanic drugs and prophylactic drugs (olanzapine, lithium, valproate) and anti-depressants (SSRIs first line). Benzos may be useful.

Summary cont.

Longer term management usually in secondary care

Includes prophylactic agents (not usually anti-depressants) and psychological input (CBT)

Primary care key role in annual physical health checks and blood monitoring for Lithium etc (NB Ace inhibitors, diuretics and NSAIDs)

Case study

Andrea is 23 yrs, and has been on fluoxetine long term for recurrent depression.

She comes to see you for a routine review and admits to having spells of feeling very excited and energetic. She hadn't thought it important to mention this before

Case study cont.

Is it appropriate to refer Andrea at this stage, and does she need an urgent appt?

Should you stop the antidepressant medication and/or give an anitmanic medication e.g. Lithium

Andrea is prescribed Olanzapine by the psychiatrist as a prophylactic agent. What monitoring do you need to do?

The end

Thank you! Any questions?claire.littlewood@shsc.nhs.uk