Bipolar Disorders & Suicide Evaluation PDF

Miranda LaCroix, PA-C  Summarize the epidemiology, etiology, pathophysiology, clinical features, how diagnosis is established including DSM-5, potential differential diagnoses, complications, treatment and patient education for bipolar disorders. Manage a patient with bipolar disorder...

Miranda LaCroix, PA-C  Summarize the epidemiology, etiology, pathophysiology, clinical features, how diagnosis is established including DSM-5, potential differential diagnoses, complications, treatment and patient education for bipolar disorders. Manage a patient with bipolar disorder noting the appropriate clinical and pharmaceutical follow-up monitoring. 2  Depression Mania Hypomania Bipolar I Yes or No Yes Yes or No Bipolar II Yes No Yes 3  It’s all about MANIA BIPOLAR I BIPOLAR II CYCLOTHYMIC DISORDER At least 1 episode of At least 1 episode of Alternating hypomanic & mania hypomania depressive symptoms that do not meet criteria for a full hypomanic or +/- Major AND Major depressive episode for at Depressive Disorder Depressive Disorder least 2 years 4  Severe Mild Euthymia Hypomania Mania Depression Depression Cyclothymia Major Depressive Disorder Bipolar Type II Bipolar Type I 5 6 GENETICS OF BIPOLAR DISORDER 40-70% risk if monozygotic twin is bipolar Greater chance of having bipolar if 1st degree relative has it 5-10% relative risk (~7x higher than general population) However, relatives more likely to develop unipolar depression than bipolar themselves Greater chance of bipolar if 1st degree relative has schizophrenia More likely to also be diagnosed with PTSD, substance use disorder, ADHD, autism 7 8 9  10 This Photo by Unknown Author is licensed under CC BY-SA  Inflated self-esteem or grandiosity. Decreased need for sleep More talkative than usual or pressure to keep talking. A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and Flight of ideas or subjective experience that persistently increased goal-directed thoughts are racing. activity or energy, lasting at least 1 week and present most of the day, nearly Distractibility every day (or any duration if hospitalization is necessary). B. During the period of mood disturbance, Increase in goal-directed activity or 3 or more of the following symptoms psychomotor agitation. have persisted (4 if the mood is only Excessive involvement in activities that have a high potential irritable) and have been present to a for painful consequences (eg, engaging in unrestrained buying significant degree: sprees, sexual indiscretions, or foolish business investments). C. Causes marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features. D. The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment) or to another medical condition. 12 13  Inflated self-esteem or grandiosity. Decreased need for sleep More talkative than usual or pressure to keep talking. A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently Flight of ideas or subjective experience that thoughts are racing. increased activity or energy, lasting at least four consecutive days and present most of 14 the day, nearly every day. Distractibility B. During the period of mood disturbance and increased energy and activity, three (or more) of Increase in goal-directed activity or psychomotor agitation. the following symptoms (four if the mood is only irritable) have persisted, represent a noticeable Excessive involvement in activities that have a high potential for change from usual behavior, and have been painful consequences (eg, engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments). present to a significant degree: C. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the individual when not symptomatic. D. The disturbance in mood and the change in functioning are observable by others. E. The episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization. If there are psychotic features, the episode is, by definition, manic. F. The episode is not attributable to the physiological effects of a substance (eg, a drug of abuse, a medication, or other treatment). 15 A. Criteria have been met for at least one manic episode B. The occurrence of the manic and major depressive episode(s) is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder. 16 A. Criteria have been met for at least one hypomanic episode and at least one major depressive episode B. There has never been a manic episode C. The occurrence of the hypomanic episode(s) and major depressive episode(s) is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other unspecified schizophrenia spectrum and other psychotic disorder. D. The symptoms of depression or the unpredictability caused by frequent alternation between periods of depression and hypomania causes clinically significant distress or impairment in social, occupational, or other important areas of functioning 17 BIPOLAR I/II WITH: Anxious distress Mixed features Rapid cycling Melancholic features Atypical features Psychotic features Catatonia Seasonal pattern 18 19 20  CYCLOTHYMIA A. For at least 2 years there have been numerous periods with hypomanic symptoms that do not meet criteria for a hypomanic episode and numerous periods with depressive symptoms that do not meet criteria for a major depressive episode. B. During the two-year period, the hypomanic and depressive periods have been present for at least half the time and the individual has not been without symptoms for more than 2 months at a time C. Criteria for major depressive, manic, or hypomanic episode have never been met 21 PSYCHIATRIC ENDOCRINE Unipolar Major Depression Hypothyroidism Schizoaffective & (myxedema coma) Schizophrenia Disorders Cushing’s Borderline Personality Hypoglycemia Disorder NEUROLOGIC INFECTIONS MS HIV/HSV Encephalitis Seizure Disorder Neurosyphilis (Temporal Lobe Epilepsy) DRUG USE 22 POOR PROGNOSIS Early age of onset Psychosis Premorbid poor occupational status Substance abuse GOOD PROGNOSIS Late age of onset Short duration of manic episodes Few suicidal thoughts No comorbid illnesses 23 MOOD STABILIZERS & ANTICONVULSANTS Lithium Valproic Acid (Depakote) Carbamazepine (Tegretol) Lamotrigine (Lamictal) Oxcarbazepine (Trileptal) ATYPICAL ANTIPSYCHOTICS Aripiprazole (Abilify) Olanzapine (Zyprexa) Quetiapine (Seroquel) Risperidone (Risperdal) TYPICAL ANTIPSYCHOTICS Haloperidol (Haldol) 24  LITHIUM ATYPICAL ANTIPSYCHOTICS Serum lithium levels 1-2 weeks, then 3-6 Baseline and annual: lipid panel months, q6 months thereafter OR Before Baseline and PRN: BG, Waist and 5 days after changing dosage circumference, body weight, CBC (if TSH and Renal function every 2-3 months for prior significant leukopenia), EKG first 6 months then every 6-12 months Twice yearly: AIMS VALPROIC ACID (DEPAKOTE) TYPICAL ANTIPSYCHOTICS Serum valproic acid levels every one to two CBC (if prior significant leukopenia) weeks Initially then every three to six baseline and monthly x 3 months or before and after dosage changes PRN: procalcitonin CBC and LFTs monthly x 2 months, then Twice yearly: AIMS every 3-12 months thereafter LAMOTRIGINE CBC and LFTs monthly x 2 months, then every 3-12 months thereafter 26 *AIMS: Abnormal Involuntary Movement Scale  ABNORMAL INVOLUNTARY MOVEMENT SCALE (AIMS) Public Health Service NAME: Alcohol, Drug Abuse, and Mental Health Administration DATE: National Institute of Mental Health Prescribing Practitioner: CODE: 0 = None 1 = Minimal, may be extreme normal INSTRUCTIONS: 2 = Mild Complete Examination Procedure (attachment d.) 3 = Moderate before making ratings 4 - Severe MOVEMENT RATINGS: Rate highest severity observed. Rate RATER movements that occur upon activation one less than those observed spontaneously. Circle movement as well as code number that Date applies. Facial and 1. Muscles of Facial Expression 01234 Oral e.g. movements of forehead, eyebrows Movements periorbital area, cheeks, including frowning blinking, smiling, grimacing 2. Lips and Perioral Area 01234 e.g., puckering, pouting, smacking 3. Jaw e.g. biting, clenching, chewing, mouth 01234 opening, lateral movement 4. Tongue Rate only increases in movement both in and out of mouth. NOT inability to 01234 sustain movement. Darting in and out of mouth. 5. Upper (arms, wrists,, hands, fingers) Include choreic movements (i.e., rapid, Extremity objectively purposeless, irregular, Movements spontaneous) athetoid movements (i.e., slow, 01234 irregular, complex, serpentine). DO NOT INCLUDE TREMOR (i.e., repetitive, regular, rhythmic) 6. Lower (legs, knees, ankles, toes) e.g., lateral knee movement, foot tapping, heel dropping, foot squirming, inversion and 01234 eversion of foot. Trunk 7. Neck, shoulders, hips e.g., rocking, 01234 Movements twisting, squirming, pelvic gyrations 8. Severity of abnormal movements overall 01234 Global 9. Incapacitation due to abnormal 01234 Judgments movements 10. Patient’s awareness of abnormal movements. Rate only patient’s report No awareness 0 01234 Aware, no distress 1 Aware, mild distress 2 Aware, moderate distress 3 Aware, severe distress 4 11. Current problems with teeth and/or Dental Status dentures No Yes No Yes 12. Are dentures usually worn? No Yes 13. Edentia? 27 *AIMS: Abnormal Involuntary Movement Scale 14. Do movements disappear in sleep? No Yes Suicide Lifetime risk of suicide in individuals with bipolar is ~15x that of the general population. Bipolar disorder may account for one-quarter of all completed suicides. A past history of suicide attempt and percent days spent depressed in the past year are associated with greater risk of suicide attempts or completions. Cognitive impairments Individuals with bipolar I disorder perform more poorly than healthy individuals on cognitive tests Approximately 30% show severe impairment in work role function.  Symptoms (may not recognize mania) Medications (risks, benefits, compliance) Family support Resources for suicidal thoughts Psychotherapy referral Follow-up schedule 33 Miranda LaCroix, PA-C 1. Assess the epidemiology, risk factors, and general screening questions for suicide risk. 2. Demonstrate effective skills to elicit information in a suicidal patient. 3. Manage a suicidal patient in both the acute setting and long-term. 4. Summarize the appropriate indications for restraints and 72 hour holds on a psychiatric patient. 35 Suicidal ideation: thoughts of killing oneself Suicidal intent: expectation or desire to die with self injurious act Suicide attempt: trying to take one’s own life but not successful Aborted suicide attempt: person stopped their plan to take their life in mid-attempt (often someone else “came to the rescue”) Suicide: intentionally taking one’s own life 36 SUICIDE RATES INCREASED APPROXIMATELY 36% BETWEEN 2000–2021. Suicide is responsible for 48,183 deaths in 2021, which is about one death every 11 minutes. An estimated 1.7 million American adults attempted suicide in 2021. SUICIDE IS THE SECOND LEADING CAUSE OF DEATH FOR PEOPLE AGES 10-14 AND 20-34 37 40 INDIVIDUAL RELATIONSHIP COMMUNITY Previous suicide attempt Bullying Lack of access to healthcare History of depression and other mental illnesses Family/loved one’s history of suicide Suicide cluster in the Serious illness such as chronic pain community Loss of relationships Criminal/legal problems Stress of acculturation High conflict or violent Job/financial problems or loss relationships Community violence Impulsive or aggressive tendencies Social isolation Historical trauma Substance use Discrimination Current or prior history of adverse childhood experiences Sense of hopelessness Violence victimization and/or perpetration 43 Effective coping and problem-solving skills Reasons for living (i.e. family, friends, pets, etc.) Strong sense of cultural identity Support from partners, friends, and family Feeling connected to others Feeling connected to school, community, religion, and other social institutions Cultural, religious, or moral objections to suicide 45 Navigating the Discussion Remain calm Engage with the patient Gain as much information as possible Obtain collateral information from friends/family 46 47  Presence/Frequency of Suicidal Thoughts “In the past few weeks, have you been thinking about killing yourself?” “How often?” (once or twice a day, several times a day, a couple times a week, etc.) “When was the last time you had these thoughts?” “Are you having thoughts of killing yourself right now?” Suicide Plan “Do you have a plan to kill yourself? Please describe.” If no plan, ask: “If you were going to kill yourself, how would you do it?” If the patient has a very detailed plan, this is more concerning Past Behavior/Diagnoses “Have a history of mental health disorders, alcohol/drug use?” “Have you ever tried to hurt yourself?” “Have you ever tried to kill yourself?” If yes, ask: “How? When? Why?” and assess intent: “Did you think [method] would kill you?” “Did you want to die?” “Did you receive medical/psychiatric treatment?” 48  Depression: “In the past few weeks, have you felt so sad or depressed that it makes it hard to do the things you would like to do?” Anxiety: “In the past few weeks, have you felt so worried that it makes it hard to do the things you would like to do or that you feel constantly agitated/on-edge?” Impulsivity/Recklessness: “Do you often act without thinking?” Hopelessness: “In the past few weeks, have you felt hopeless, like things would never get better?” Anhedonia: “In the past few weeks, have you felt like you couldn’t enjoy the things that usually make you happy?” Isolation: “Have you been keeping yourself more than usual?” Irritability: “In the past few weeks, have you been feeling more irritable or grouchier than usual?” Substance and alcohol use: “In the past few weeks, have you used drugs or alcohol excessively or more than usual?” If yes, ask: “What? How much? Has this caused any legal problems or problems with more people in your life?” Other concerns: “Recently, have there been any concerning changes in how you are thinking or feeling? Or changes in your mood that we haven’t discussed?” 49  Social Support and Stressors Support network: “Is there a trusted person you can talk to? Who? Have you ever seen a therapist/counselor?” If yes, ask: “When and for what purpose?” Family situation: “Are there any conflicts at home that are so difficult to manage that they are causing you a lot of distress?” Employment: “Do you currently have a job?” If yes, ask: “Do you ever feel so much pressure at work that you can’t take it anymore?” Domestic violence: “Are you worried that anyone in your life is trying to hurt you?” Suicide contagion: “Do you know anyone who has killed themselves or tried to kill themselves?” Reasons for living: “What are some of the reasons you would NOT kill yourself?” (e.g. belief system/faith/family/other)” 50  Risk Stratification 52  High Risk Moderate Risk Low Risk Intensive Outpatient or Hospitalization Partial Hospitalization PCP follow-up (EMS vs family transport) Treatment (ED eval à possible Weekly appointments Mental Health referral Regular reassessment psychiatric Mental Health referral Psychotherapy hospitalization) Safety Plan Lethal Means Reduction Counselling Consider hospitalization Discussion of warning signs, the fluidity of suicide risk, and information about how to get help 24 hours a day, 7 days a week using the National Suicide Prevention Lifeline 988 OR 1-800-273-TALK (8255) and Crisis Text Line: text GOT5 to 741-741 53 Hospitalization 54  There are two types of emergency holds permitted under Minnesota law. These holds have different functions and operate independently of each other. These include the Peace Healthy Officer Authority (formerly known as the transportation hold) and 72-Hour Hold. 55 PEACE HEALTHY OFFICER AUTHORITY (PHOA) A PHOA allows an officer to take a person into custody and transport them to a treatment facility, state-operated treatment program or community-based treatment program if the person is mentally ill (MI), developmentally disabled (DD), chemically dependent (CD), or intoxicated in public and is in danger of harming themselves or others if not immediately detained. 72-HOUR HOLD Allows the hospital to involuntarily hold a patient who is MI, DD or CD, and a substantial likelihood of danger or harming themselves or others if not immediately detained. 56  After examining the patient and if reason to believe the patient is MI, DD, or CD and is in danger of harming themselves or others if not immediately detained, the practitioner may place the patient on a 72-Hour Hold. When ordering the hold in the EHR: Document the need for the 72-Hour Hold referencing specific, required hold criteria. The ME will also document, to the extent available: Direct observations of the proposed patient’s behaviors Reliable knowledge of recent and past behavior Information regarding psychiatric history, past treatment, and current mental health providers Identity of specific individuals in danger that are a basis for the emergency hold Inquire into the existence of health care or psychiatric advance directives. 57  A patient placed on an emergency hold may be held for up to 72 hours exclusive of weekends and legal holidays. The 72-Hour Hold may be discontinued and the patient released prior to the expiration of the hold period if a ME determines that the patient no longer meets 72- Hour Hold criteria. 58  Partial Hospitalization/ Intensive Outpatient 59 Safety Plan 60 Means Reduction Counseling Ask directly about suicide Inquire about means Ask individuals directly if they have thoughts about how they would attempt suicide Do they have access to any preferred method? Ask about past attempts and any means used. Focusing on details is key. Educate the moderate and high-risk individual and reduce access to lethal means When possible, include trusted people in the individual’s life to aid in reducing access. Consider providing prescriptions weekly instead of monthly. Limit supplies of non-prescription medications and encourage disposal of any expired medications. Not everything can be removed and one cannot eliminate all risk completely. If a high-risk individual’s preferred means is related to the environment (e.g., jumping off a bridge or in front of a train), engage the individual in ways to avoid potentially dangerous places or situations. If the individual’s preferred method involves hanging, inquire as to whether there is a preferred object that can be removed (such as a rope or tie). Alcohol reduces impulse control and increases the risk of suicide. Counsel about reducing access to alcohol and other substances. Maintain a collaborative stance; make sure the discussion does not become adversarial. Work towards possible solutions and compromises using motivational strategies where appropriate. Engage the suicidal individual in actively suggesting ways to improve safety. Stress that the goal of means reduction counseling is to make the individual’s environment as safe as possible. 61 Consider each med & their potential lethality in an overdose Lithium & Clozaril: only medicines that have shown to decrease suicide risks ECT can be helpful – usually last resort 62  SUICIDE HOTLINE ZERO SUICIDE 988 Call or Text Suicide Resources for Providers https://988lifeline.org/chat/ zerosuicide.edc.org CANVAS HEALTH TREVOR PROJECT Crisis Services, CM, Therapy Younger LGBTQ Support www.canvashealth.org www.thetrevorproject.org/ 63  Suicide is the most common cause of legal action against mental health professionals If it isn’t written down, it didn’t happen Simply asking questions such as “are you suicidal,” “do you have a plan,” “do you have the means” is inadequate for defending against allegations of negligence Contracts for safety are not reliable, nor do they stand up in court, better to document safety plan that was agreed upon i.e. call 911 if unsafe, do not be alone, call crisis hotline, etc. Document info from collateral sources (i.e. old records, family, etc.) Document conversation about access to firearms and the instructions to patient and family about the removal of those items 64 65