Patient Management Exercise for Bipolar Disorder
Abstract
This exercise is designed to test your comprehension of material presented in this issue of FOCUS as well as your ability to evaluate, diagnose, and manage clinical problems. Answer the questions below, to the best of your ability, on the information provided, making your decisions as you would with a real-life patient.
Questions are presented at “consideration points” that follow a section that gives information about the case. One or more choices may be correct for each question; make your choices on the basis of your clinical knowledge and the history provided. Read all of the options for each question before making any selections. You are given points on a graded scale for the best possible answer(s), and points are deducted for answers that would result in a poor outcome or delay your arriving at the right answer. Answers that have little or no impact receive zero points. At the end of the exercise, you will add up your points to obtain a total score.
Case vignette
Robert is a 28-year-old male who was referred to you by his internist; he moved to town a month earlier and had asked his primary care physician for referral to help with the management of bipolar disorder.
When he scheduled his initial appointment, Robert had reported that “I've had bipolar disorder since college and need help with my meds.” The referral form indicated diagnoses of “bipolar disorder, hypothyroidism, mild chronic renal compromise.”
When the patient came in for his evaluation, he reported that he had been “frequently sad and moody” as a child but had first come to psychiatric attention while he was a college freshman. He related that “I had been stressed out with my first semester finals. I guess I was studying around the clock for a few days when I ‘lost it’… my mind went into overdrive, I didn't need to sleep or eat, and I thought that I didn't need to study any more because I would get the test answers telepathically from Zeus … which sounds crazy, I know, but at the time it felt so real.” He reported that he showed up for an exam dressed in a toga, with a wreath of ivy in his hair, “talking a blue streak,” and the campus security staff escorted him to the hospital; he was an inpatient for “about a week,” during which time he received lithium and olanzapine. After 2 months, his olanzapine dose was tapered and then discontinued, and he was managed on lithium alone for about 9 months before he persuaded the student health psychiatrist to discontinue it as well.
He did well for a year before he slumped into a depression in the context of “more than social” alcohol consumption at his fraternity and a full course load; poor academic performance happened at the same time, but he was unsure “which was the chicken and which was the egg” in terms of his depression and his academic failings. After about a month of “feeling like my world was falling apart,” he attempted suicide via lithium overdose; he was found by a roommate who called 911. He was hospitalized in the intensive care unit with acute renal failure, requiring hemodialysis temporarily for 2 weeks. Although medically stable, he was still endorsing active suicidal ideation at that point, and recalled “My life was going down the tubes and I really wanted to be dead. If I had been a little more brave, I would have done something lethal at dialysis.” Given the urgency of his situation, he received a course of electroconvulsive therapy (ECT), to which his mood and suicidal urges responded. After ECT, valproate (the divalproex formulation) was started and he did well; he took the semester off to “get my life back in balance” and to recover more fully from the cognitive side effects of his ECT treatment. After some initial protestations, he engaged in psychodynamic psychotherapy and learned more fully the importance of medications in staying well. He described that he began to be adherent to treatment, and his mood was generally stable. He denied any other periods of believing he had special powers such as his telepathic belief.
His academic performance improved considerably and he was able to graduate with honors in business administration. He entered a management training track at the regional office of a large company, which is headquartered in your area, and had done well over the past several years. He was promoted to a position in the main office and moved to town. He reported that it has been challenging to make new friends in this new locale but that his work was going well, although with a bit more stress and longer hours than he had imagined would be the case.
Consideration Point A:
At this point in your evaluation, the diagnosis that seems most appropriate for this patient would be
| A1._____ | Bipolar disorder type I |
| A2._____ | Bipolar disorder type II |
| A3._____ | Bipolar disorder not otherwise specified |
| A4._____ | Schizoaffective disorder, bipolar type |
Vignette continues
As your patient detailed more about his present situation, he voiced concern about staying well, now that he was working long hours and had less social support than he had before he moved. He asked for your recommendations as to therapeutic options.
Consideration Point B:
At this point in your evaluation and given that he is currently euthymic, which treatments would you consider as having a favorable risk-to-benefit balance?
| B1._____ | Valproate |
| B2._____ | Lithium |
| B3._____ | Aripiprazole, quetiapine, or ziprasidone |
| B4._____ | Social rhythm therapy |
Vignette continues
The patient decided to follow your recommendations for continued use of valproate and for seeing a therapist for social rhythm therapy. He did well for 6 more months, then started to note the return of some depressive symptoms—sleeping longer than expected, feeling lethargic during the day, and experiencing difficulties in making decisions about prioritizing tasks at work. He called to set up a visit sooner than his scheduled follow-up appointment, because “my mood is depressed more days than not, and I'm worried about another full-blown episode.” When he comes to the office, he described that he also had feelings of guilt with low self-esteem about “not deserving my job,” and feeling like he was “weighed down … my shoulders feel like they're covered in cement.” He told you he has been strictly adherent to daily valproate and has been trying to temper his social patterns as his therapist had taught him.
Consideration Point C:
What recommendation do you offer the patient at this point?
| C1._____ | Offer a trial of an adjunctive selective serotonin reuptake inhibitor (SSRI), starting at a low dose |
| C2._____ | Refer him for cognitive behavior psychotherapy |
| C3._____ | offer a trial of quetiapine monotherapy or of olanzapine-fluoxetine combination (OFC) treatment. |
Vignette concludes
With combined pharmacotherapy and psychotherapy, with valproate, an atypical antipsychotic agent, and cognitive behavior therapy, Robert's depressive symptoms came under control. He adjusted his schedule and used a second alarm clock to regularize his bedtime. He started volunteering at a nonprofit organization focused on “greening” the town (e.g., with tree planting events), and widened his circle of friends. He also built a program of exercise into his weekly schedule to avoid any weight gain associated with his medication. He continued to do well in follow-up.
Answers: scoring, relative weights, and comments
Consideration Point A:
| A1._____ | +3 Bipolar disorder type I. The presence of a past manic episode with psychotic features (delusions about special telepathic communication with Zeus) is most parsimonious with a diagnosis of bipolar disorder type I (1). |
| A2._____ | +0 Bipolar disorder type II. Bipolar II is characterized by a history of depressive episodes, as this patient experienced, but with hypomanic rather than manic episodes (1). |
| A3._____ | +0 Bipolar disorder not otherwise specified. The not otherwise specified subtype is frequently applied to situations in which fluctuations in the patient's mood state do not fit compellingly into framework for manic, hypomanic, or depressed episodes of the DSM, for example, where the periods of energized, elevated mood last only 1 or 2 days (too brief for true manic episode) (1). |
| A4._____ | +0 Schizoaffective disorder, bipo-lar type. Had the patient reported a period in which psychotic symptoms were present while his mood was euthymic, then a diagnosis of schizoaffective disorder would have been more fitting than bipolar I (1). |
Consideration Point B:
| B1._____ | +2 Valproate. This agent was useful for maintenance treatment after the patient's suicide attempt and course of ECT. Although it does not have an U.S. Food and Drug Administration (FDA) indication for use as a maintenance agent (2), the practice guidelines from APA (3), the CANMAT Guidelines (4), and others have recommended the use of this agent for maintenance. |
| B2._____ | -2 Lithium. Although lithium is a time-tested mood stabilizer for patients with bipolar disorder, has shown use in suicidal ideation (5, 6), and was useful to this individual in the past, he has already experienced renal toxicity, and, in the interest of avoiding additional organ damage, other treatments merit consideration. |
| B3._____ | +2 Aripiprazole, quetiapine, ziprasidone. On the basis of clinical trials submitted to the FDA, these agents all have received an FDA indication for use as maintenance therapy in bipolar I disorder, when used as an “adjunct to lithium or valproate” (7–9) Risperidone has an indication in acute mania but not as an agent for maintenance treatment (10). Olanzapine has an indication for use in acute manic and mixed episodes as an adjunct to lithium or valproate (11). Paliperidone has an indication in schizoaffective disorder but not bipolar depression (12). |
| B4._____ | +2 Social rhythm therapy. Social rhythm therapy is a nonpharmacologic treatment in which attention to the rhythms of behaviors can lead to improved symptomatic stability (13, 14). |
Consideration Point C:
| C1._____ | +1 SSRI pharmacotherapy. Controlled trials have reported mixed results, with some patients experiencing benefitting but other experiencing no benefit and others developing a manic episode (“switching” or “flipping”) (3) |
| C2._____ | +3 Cognitive behavioral therapy. Published evidence supports the use of CBT in the treatment of the depressive phase of bipolar disorder (15). “The goals of the program are to educate the patient regarding bipolar disorder and its treatment, teach cognitive behavior skills for coping with psychosocial stressors and attendant problems, facilitate compliance with treatment, and monitor the occurrence and severity of symptoms.” (3) |
| B3._____ | +3 Quetiapine or OFC. Both these products have indications for use in the depressed phase of bipolar disorder (3, 8, 16). Many practitioners may use agents off-label, such as aripiprazole [has indications for maintenance treatment and for adjunctive treatment in unipolar major depressive disorder, but not in bipolar depression (7)] or ziprasidone [has an indication for maintenance treatment but not explicitly in bipolar depression (9)]. |
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