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Independent learning program for GPs

Unit 468 March 2011

Bipolar
disorders
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Independent learning program for GPs

Medical Editors
Kath OConnor
Catherine Dodgshun

Bipolar disorders

Editor
Nicole Kouros

Unit 468 March 2011

From the editor

Case 1

Adam presents with depression

Case 2

Sue complains of depression and irritability

Case 3

Sally hasnt 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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Authors
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David Castle
Leon Piterman
Kay Jones
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from the editor

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 Vincents 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 Vincents 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 osteoarthritis, 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. Iam commencing a new
role as a medical editor with Australian Family Physician, alongside senior medical editor, Dr Carolyn OShea and
medical editor, Dr Rachel Lee. I wouldlike to extend a warmwelcome to the incoming check medical editor, Dr
Catherine Dodgshun.
Working on check has been an extremelyrewarding experience. I am grateful to all theauthors and reviewers I
have worked withfor the generous gift of their time and expertiseand 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 OConnor
Medical Editor

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Case 1

check Bipolar disorders

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 in
the 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.

Question 1
What is your differential diagnosis for Adams presentation?

Further history
Adam lives with his girlfriend 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, Adams 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 didnt 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 doesnt think anything is wrong and refuses to seek
medical attention.
Question 4
What is the differential diagnosis now?

Question 2
What are some of the risks associated with Adams symptoms?

Question 5
What are the risks associated with a manic episode?
Question 3
How would you assess Adams risk of suicide?

Case 1

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Question 6

Question 9

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

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

Question 10
Further history
Adam was taken to hospital under the Mental Health Act
after being assessed by the on call psychiatry team. He spent
3 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 doesnt think
anything was ever wrong, he has been taking his medication.

Describe your initial and ongoing management of Adam.

Question 7
Does Adam have bipolar disorder?
Case 1 Answers

Question 8
What is the typical first presentation of bipolar disorder?

Answer 1
The differential diagnosis in Adams 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 Adams 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

Case 1

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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

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:

Drug intoxication or withdrawal

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


or illicit drugs)

Organic/medical conditions

bipolar disorder either a manic episode or a mixed episode

Metabolic and endocrine conditions (eg. thyroid and glucocorticoid


disturbances)

a psychotic disorder (eg. schizophrenia)

Drug and/or alcohol abuse or dependence

Infection, postinfective states


Nutritional deficiency (eg. vitamin B12, folate)
Anaemia

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

Malignancy
Sleep related disorders, especially sleep apnoea

Answer 5
Potential risks associated with a manic episode include:2

Normal life stressors

risk taking behaviour resulting from a belief that one is invulnerable

Bereavement (which can be normal or pathological)

excessive spending

Other psychosocial stressors

alcohol or substance use and the risks associated with intoxication


(people with psychiatric symptoms often self medicate with drugs or
alcohol)

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

Modified and reproduced with permission from McGraw-Hill Australia

occupational problems possibly leading to unemployment

irritability, aggression and socially disruptive behaviour

financial problems.

disinhibited behaviour such as uncharacteristic sexual activity,


including the associated risks (eg. sexually transmitted infection)

Answer 3
Assessing risk of suicide in depression includes the following.

inappropriate behaviour (eg. being sarcastic, rude, aggressive) that


can damage reputation

Ask questions about suicidal intent:

risks related to a potential undiagnosed medical condition (eg.


cerebral neoplasm, HIV infection).

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

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 psychiatric
team (see Resources on call services are available in most
metropolitan areas of Australia).
Advice to Caity could include:
explaining what might be causing Adams behaviour (eg. mania,
drugs, medication) but importantly that further evaluation is needed
in order to be able to determine the cause of Adams symptoms and
initiate appropriate treatment
emergency contingency management, for instance, if Caity feels that
Adams symptoms or behaviour are placing her or someone else at
immediate risk of harm, she should contact the police

Case 1

check Bipolar disorders

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 dont think they
need help (see Resources for links to state and territory mental
health acts).

The symptoms do not meet criteria for a mixed episode

Supporting Caity and her situation is important. Balancing


confidentiality 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 Psychiatrists Code of Ethics
provides some guidelines on maintaining confidentiality these
guidelines apply to GPs as well as psychiatrists (see Resources).

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).

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.

Criteria for diagnosing a hypomanic episode4

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 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

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
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 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 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?

Case 1

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

seasonal or postpartum pattern

Feel more confident and capable?

hyperphagia and hypersomnia

feel very creative with lots of ideas and plans?

early age at depression onset

spend or wish to spend significant amounts of money?

delusions, hallucinations or other psychotic features.

work harder and are more motivated?

These features are a flag of possible bipolarity in:

feel irritated?
have an increased interest in sex?

depressed patients in whom past history of hypomanic or manic


episodes is ambiguous

talk over people?

depressed patients with a family history of bipolar disorder

do fairly outrageous things?

young patients with recurrent depressive episodes.

sleep less and not feel tried?

These features are not perfectly sensitive, as illustrated by Adams 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

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. One
study 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 a
psychiatrist 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 patients history
irritable
psychomotor retardation or agitation

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 Adams comorbidities
ensuring Adam understands the risks of marijuana use
monitoring Adams 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
lipids1214
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.

loaded family history


abrupt onset or termination of depressive bouts

Case 2

Case 2
Sue complains of depression and
irritability

check Bipolar disorders

Question 2
What is your differential diagnosis?

Sue is 52 years of age with a past history of


hypercholesterolaemia, hypertension and obesity
(BMI: 31 kg/m2).
She presents complaining that her partner 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.

Question 1
Is menopause associated with depression?
Question 3
What are the symptoms and signs of mania and hypomania? What
factors distinguish mania from hypomania?

Further history
About 10 months ago, Sue had a 4 month period of pervasive
low 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 didnt complete any of them. Bill had
commented that she didnt stop talking which contrasted to
her usual somewhat taciturn state. These symptoms resolved
a 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 doesnt use drugs or alcohol.

Question 4
What investigations should be done?

Case 2

check Bipolar disorders

Question 5

Question 8

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


GP refer a patient with suspected or established bipolar disorder?

What is the main source of disability in 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 9
Sue asks for more information. What resources can you refer her to?

Question 6
How do people with bipolar II disorder typically present?

Question 10
Sue tells you that she had CBT once, but it didnt 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 7
Is bipolar II disorder less severe than bipolar I disorder?

Case 2

check Bipolar disorders

Question 11

Question 13

What ongoing monitoring is required once serum lithium levels are


stable? What are the symptoms and signs of toxicity?

Should hormone replacement therapy (HRT) be considered for Sues


affective symptoms?

case 2 AnswerS
Question 12
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

What might happen if Sue abruptly stopped taking lithium?

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 Sues case, her
menopausal symptoms may also need treatment.

Changes associated with menopause and depression


Depression

Menopause

Low mood

Fatigue

Menstrual irregularity, amenorrhoea

Irritability

Poor concentration

Anhedonia

Insomnia

Vasomotor disturbance
(hot flushes, diaphoresis)

Suicidality

Weight change (usually gain in menopause)

Vaginal atrophy and dryness

Feelings of worthlessness

Irritability

Osteoporosis

Psychomotor agitation/retardation

Libido change

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

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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

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 ones 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

Case 2

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 patients presentation, the GPs experience, the support
available from psychiatric services, and the patients preference. In
Sues 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 depressive
episodes. 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

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

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

11

Case 2

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 3050% of the patients
life, while manic symptoms affect about 510%.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
dont suit some patients. So in Sues situation, she may wish to try
other psychological strategies. Possibilities for Sue include:10
further psychoeducation
interpersonal and social rhythm therapy

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 patients 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

12

check Bipolar disorders

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 benefits
and 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 36 months once a stable level is
achieved (aim for 0.60.8 mmol/L for maintenance therapy)12,17
serum urea and creatinine every 36 months
thyroid stimulating hormone, serum calcium, weight at 6 months
then annually.
Lithium can cause hypothyroidism and hyperthyroidism,
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.

Case 3

check Bipolar disorders

Case 3
Sally hasnt been her usual self

Question 3
How would you clarify Sallys diagnosis?

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 emergency
department by friends after she cut her foot on
some glass at a nightclub.
Sallys 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

Question 4
Sallys father has bipolar disorder. How does this affect her risk of
developing bipolar disorder?

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.

Question 1
What is your differential diagnosis for Sallys presentation?

Further INFORMATION
After Sallys 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 68 standard drinks every
other day. She also thinks she might be pregnant.
Question 5

Question 2

List some of the aspects of Sallys physical health which you need
to address.

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

13

Case 3

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Question 6

Question 9

What are the problems associated with sodium valproate in this


patient? What other medication strategies might you consider?

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

Question 7
How would you address Sallys ongoing substance use?
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.

Question 8
What are the stages of behavioural change? How would you
structure the questions you ask about a patients stage of change?
What intervention would you consider for each stage?

Answer 2
Acutely, one of the most characteristic effects 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 Sallys 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.

14

Case 3

check Bipolar disorders

Answer 3
Sallys 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 510 times that
of the general population.26
Answer 5
The following aspects of Sallys physical health need to be
addressed.
Pregnancy testing and contraception given that many
pregnancies are unplanned, it is important to discuss the
possibility 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 for
PCR 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 Sallys 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 15% 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 of 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 Sallys 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.

15

Case 3

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 making
in each of these stages. The type of intervention varies depending on
the stage of Sallys 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 Sallys depression include the following.
Dealing with Sallys 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 supportive
psychotherapy, 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 12 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.

16

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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 as
appropriate
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 Medical Journal of Australia

Case 3

check Bipolar disorders

Table 6. Stages of change and interventions28,29


Stage of change

Characteristics

Questions to the patient

Intervention

Precontemplation

Not thinking about change

Goal: patient to begin


thinking about change

May be resigned

What warning signs would let you know


that this is a problem?

Educate patient about substance


misuse

Feeling of no control

How will you know when it is time to quit?

Denial does not believe it applies


to self

Have you tried to change in the past?

Help the patient to examine problems


with their current behaviour

Why do you want to change at this time?

Explore pros and cons of change

What were the reasons for not changing?

Acknowledge patients ambivalence


and resistance to change

Believes consequences are not


serious
Contemplation
Goal: patient to examine
benefits and barriers to
change

Weighing benefits and costs of


behaviour and proposed change

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?

Preparation

Experimenting with small changes

Have you tried doing anything differently?


What do you think has been helpful, or
unhelpful?

Help patient to determine the most


appropriate strategies for change

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)?
Action

Taking a definitive action to change

Do you have any questions about this


action?

Assist patient to instigate planned


changes

How have things been going with this


action?
What aspect of this action have you found
most effective?
Maintenance

Maintaining new behaviour over


time

Could you tell me about some prevention


strategies youve learned?

Encourage new skills


Rehearse relapse revention strategies

Have there been any times where you were


close to using again?
Could we talk about ways of dealing with
these 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.
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

17

Case 4

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, cant 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.

check Bipolar disorders

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?

Sam lost his job due to altercations with his


colleagues and boss, and broke up with his
girlfriend 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 and
dropped 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 drivers licence for speeding.

Question 1
What is your differential diagnosis for Sams presentation?

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, Sam
complains of poor sleep. As Sams 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 cant 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 between
bipolar disorder and ADHD?

18

Case 4

check Bipolar disorders

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?

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?

Question 5
What is the relationship between bipolar disorder and ADHD in
adults?

Case 4 Answers
Answer 1
The differential diagnosis is:
major depression with irritability
anxiety disorder
substance-induced mood disturbance
bipolar disorder (mixed episode)
Question 6

adjustment disorder

What further treatment options might you consider and what are the
risks and benefits?

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.

19

Case 4

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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 4
The 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

Extensive

Distractibility

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

Difficulty settling
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

of childhood ADHD must be obtained, beginning with a good


developmental history. Reviewing Sams 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 hyperactivity
has 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 Handbook37 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 Sams drug and alcohol comorbidities
should also be implemented (eg. motivational interviewing,39 as well as
psychological treatments aimed at bipolar disorder).10

Bipolar depression

ADHD

Degree of
overlap

Depressed mood

Dysphoria

Extensive

Insomnia

Difficulty settling

Extensive

Irritability

Irritability

Extensive

Difficulty concentrating

Inattention

Extensive

antidepressants

Psychomotor agitation

Hyperactivity

Moderate

benzodiazepines

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

Reproduced with permission from Springer

20

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)

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
Reproduced with permission from Springer

Case 5

check Bipolar disorders

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 lowlevel 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 showed
mild 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 lowlevel 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 hasnt 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 some
diarrhoea.
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 examinations
are normal. A serum lithium level is 1.5 mmol/L; urea,
electrolytes and creatinine are normal.

Question 1

Question 2

What is the differential diagnosis for Mrs Smiths presentation? What


is the most likely diagnosis?

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

21

Case 5

Question 3
What is your short term management plan?

check Bipolar disorders

Case 5 Answers
Answer 1
Differential diagnoses in this scenario include delirium, dementia and
depression. Delirium secondary to lithium toxicity is the most likely
cause of this presentation. Note that delirium is often misdiagnosed
as depression.4042 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

Question 4
Over the longer term, what monitoring and follow up should Mrs
Smith have?

It is essential to consider delirium in differential diagnosis in an


elderly person who is presenting with emotional, cognitive, or
behavioural 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 Smiths delirium has been treated, but dementia would not
account for her acute change (Table 10).

Table 10. Clinical features of delirium verses dementia


Feature

Delirium

Dementia

Onset

Rapid

Insidious

Primary deficit

Attention

Short term memory

Course

Fluctuating

Progressive

Question 5

Duration

Days to weeks

Months to years

Are psychological treatments for bipolar disorder indicated in the


elderly? Would these be helpful for Mrs Smith?

Consciousness

Clouded

Clear

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

22

Case 5

check Bipolar disorders

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 patients usual intellectual performance. Differential
diagnoses include dementia and mood disorders, especially
depression (delirium is often misdiagnosed as depression).4042
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.

Table 11. Common misunderstandings about delirium41


The typical presentation is of delirium tremens (ie. agitated, floridly
psychotic)

recommended lithium ranges for acute mania are usually


0.81.2 mmol/L. Lower ranges (eg. 0.60.8 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 0.50.8 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 Smiths 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 of
major depression or mania.

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 patients 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 of
Psychiatrists, London

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 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 Smiths current state, psychological
interventions (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

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

23

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


180188.
2. Bassett DL. Risk assessment and management in bipolar disorders.
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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. Cades disease and beyond:
misdiagnosis, antidepressant use, and a proposed definition
for bipolar spectrum disorder. Canadian Journal of Psychiatry
2002;47:12534.
6. Michell PB, Loo CK, Gould BM. Diagnosis and monitoring of bipolar
disorder in general practice. MJA 2010;193:S10S13.
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;64:16174.
8. Pies R. Is it bipolar depression? WHIPLASHED aids diagnosis.
Current Psychiatry 2007;6:8081.

check Bipolar disorders

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


of cannabis in humans. In: Castle D, Murray R, editors. Marijuana
and madness: psychiatry and neurobiology. Cambridge: Cambridge
University Press, 2004;4153.
24. Degenhardt L, Hall W, Lynskey M, et al. The association between
cannabis 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;5474.
25. Parker G. Comorbidities in bipolar disorder: models and management.
MJA 2010;193:S18S20.
26. Craddock N, Jones I. Molecular genetics of bipolar disorder. Br J
Psychiatry 2001;178:S128S133.
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 University
Press, 2006;185211.
28. Lubman DI, Sundram S. Substance misuse in patients with
schizophrenia: a primary care guide. MJA 2003;178:S71S75.
29. Prochaksa JO, DiClemente CC, Norcross JC. In search of how people
change: applications to addictive disorders. American Psychologist
1992;47:110214.

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


practice: challenges and opportunities. MJA 2010;193:S14S17.

30. Kessler RC, Adler L, Barkley R, et al. The prevalence and correlates
of adult ADHD in the United States: results from the National
Comorbidity Survey Replication. Am J Psychiatry 2006;163:71623.

10. Lauder SD, Berk M, Castle DJ, et al. The role of psychotherapy in
bipolar disorder. MJA 2010;193:S31S35.

31. McGough JJ, Barkley RA. Diagnostic controversies in adult attention


deficit hyperactivity disorder. Am J Psychiatry 2004;161:19481956.

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


with bipolar affective disorder. Advances in Psychiatric Treatment
2004;10:1826.

32. Ward MF, Wender PH, Reimherr FW. The Wender Utah Rating Scale:
an aid in the retrospective diagnosis of childhood attention deficit
hyperactivity disorder. Am J Psychiatry 1993;150:88590.

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


bipolar disorder in primary care. MJA 2010;193:S24S30.

33. Conners CK, Erhart D, Sparrow E. Conners Adult ADHD Rating


Scales, technical manual. New York, NY: Multi-Health Systems, 1999.

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


recommendations for bipolar disorder. Acta Psychiatrica Scandinavica
2009;119(Suppl 439):2746.

34. Scheffer RE. Concurrent ADHD and bipolar disorder. Curr Psychiatry
Rep 2007;9:41519.

14. Conn TA, Sernyak MJ. Metabolic monitoring for patients treated
with antipsychotic medications. Canadian Journal of Psychiatry
2006;51:492501.
15. Dennerstein L, Alexander JL. Mood and menopause. In: Castle DJ,
Kulkarni J, Abel KM, editors. Mood and anxiety disorders in women.
Cambridge University Press: Cambridge, 2006;212241.
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):1621.
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;38:280305.

35. Sobanski E. Psychiatric comorbidity in adults with attention-deficit/


hyperactivity disorder (ADHD). European Archives of Psychiatry and
Clinical Neurosciences 2006;256(Suppl 1):26i31
36. Nierenberg AA, Miyahara S, Spencer T, et al. Clinical and diagnostic
implications of lifetime attention-deficit/hyperactivity disorder
comorbidity in adults with bipolar disorder: data from the first 1000
Step-BD Participants. Biological Psychiatry 2005;57:146773.
37. Editorial Advisory Board. Australian Medicines Handbook 2010.
Adelaide: Australian Medicines Handbook Pty Ltd, 2010.
38. Knight LA, Rooney M, Chronis-Tuscano A. Psychosocial treatments
for attention-deficit/hyperactivity disorder. Current Psychiatry Reports
2008;10:412418.
39. Treasure J. Motivational interviewing. Advances in Psychiatric
Treatment 204;10:3317.

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


2010;193:S5S9.

40. Inouye S. Delirium in older persons. N Engl J Med 2006;354:1157


65.

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


2005;7:1121.

41. Meagher DJ, Moran M, Raju B, et al. Phenomenology of delirium. Br


J Psychiatry 2007;190:135141.

20. Lam-Po-Tang J, McKay D. Dr Google, MD: a survey of mental healthrelated internet use in a private practice sample. Australas Psychiatry
2010;18:1303.

42. Meagher D, Leonard M. The active management of delirium:


improving detection and treatment. Advances in Psychiatric Treatment
2008;14:292301.

21. National Collaborating Centre for Mental Health. Bipolar disorder: the
management 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.

43. Murray L. Lithium. In: Cameron P, Jelinek G, Kelly A, et al, editors.


Textbook of adult emergency medicine. 2nd edn. Edinburgh: Churchill
Livingston, 2004;87480.

22. Psychotropic Expert Group. Therapeutic Guidelines: psychotropic.


Version 6. Melbourne: Therapeutic Guidelines Limited, 2008.

24

44. Garner J. Psychotherapies and older adults. Aust N Z J Psychiatry


2003;37:53748.

resources

check Bipolar disorders

PROFESSIONAL RESOURCES

RESOURCES FOR PATIENTS AND CARERS

Bipolar disorder: new understandings, emerging treatments. MJA


Supplement 16 August 2010;193. Available at www.mja.com.au/
public/issues/193_04_160810/contents_suppl_160810.html

SANE Australia: www.sane.org

GP Psych Support Service provides advice for GPs from a


psychiatrist via phone, fax or secure email and is available
24 hours per day, 7 days per week. Tel 1800 200 588
Fax 1800 012 422. Available at www.psychsupport.com.au
The Royal Australian and New Zealand College of Psychiatrists
Code of Ethics. Available at www.ranzcp.org/resources/conductand-ethics.html
Motivational interviewing in general practice. check Program
October 2009;unit 451.

STATE AND TERRITORY OUTREACH OR ON CALL


PSYCHIATRIC SERVICES
24 hour mobile on call psychiatric services are available in most
(but not all) parts of Australia.
Australian Capital Territory
Crisis Assessment and Treatment Team (CATT)
http://health.act.gov.au/c/health?a=sp&pid=1061186615
Tel 1800 629 354 (24 hour service) or 02 6205 1065
New South Wales
Crisis Service/Team or CATT
www.health.nsw.gov.au/mhdao/contact_service.asp
Northern Territory
Alice Springs Community House Crisis Assessment Team
CATT www.health.nt.gov.au
Tel 08 8951 7710 (business hours) or 08 8951 7777 (after hours)
Top End Mental Health Service
Tel 08 8999 4988
Queensland
Mobile Intensive Support Team (MIST/MIT)
Also ACTT/ACS: www.health.qld.gov.au/mentalhealth
South Australia
Assessment and Crisis Intervention Service (ACIS)
www.health.sa.gov.au/mentalhealth
Statewide Emergency Crisis Tel 131 465
Rural and Remote Emergency Triage and Liaison Tel 131 464
Tasmania
CATT www.dhhs.tas.gov.au/mentalhealth
Tel 1800 332 388
Victoria
CATT. Available at www.health.vic.gov.au/search.htm?q=CAT+Team
Western Australia
The Mental Health Emergency Response Line (or Rural Link in rural
areas) takes referrals, the Community Emergency Response Team
(CERT) and Acute Community Intervention Team (ACIT) provide
assessment and treatment. Available at www.mentalhealth.wa.gov.
au Tel 1300 555 788 or 1800 332 388

beyondblue: www.beyondblue.org.au
Black Dog Institute: www.blackdoginstitute.org.au
Victorian Better Health Channel: www.betterhealth.vic.gov.au/
bhcv2/bhcarticles.nsf/pages/Bipolar_disorder?open
MoodSwings is an online self-help program for bipolar disorder.
Intake of registrations may vary with time. Information on this site
is also relevant. www.moodswings.net.au
Multicultural Mental Health Australia: www.dhi.gov.au/
Multicultural-Mental-Health-Australia/default.aspx.
The following online self management programs are directed at
depression and anxiety, but are applicable to bipolar disorder,
particularly as anxiety is a common comorbidity:
Moodgym: www.moodgym.anu.edu.au
E-couch: http://ecouch.anu.edu.au
Anxiety online: www.anxietyonline.org.au.

STATE AND TERRITORY MENTAL HEALTH ACTS


Australian Capital Territory Mental Health (Treatment and Care)
Act 1994. Available at www.legislation.act.gov.au/a/1994-44/
default.asp
New South Wales Mental Health Act, 2007. Available at
www.austlii.edu.au/au/legis/nsw/consol_act/mha2007128
Northern Territory Mental Health and Related Services Act, 2010.
Available at www.health.nt.gov.au/Mental_Health/Legislation/
index.aspx and www.austlii.edu.au/au/legis/nt/consol_act/
mharsa294
Queensland, Mental Health Act, 2000. Available at www.health.
qld.gov.au/mha2000
South Australia Mental Health Act, 2009. Available at www.
austlii.edu.au/au/legis/sa/consol_act/mha2009128/index.html
Tasmania Mental Health Act, 1996. Available at www.austlii.edu.
au/au/legis/tas/consol_act/mha1996128
Victoria Mental Health Act, 1986. Available at www.austlii.edu.au/
au/legis/vic/consol_act/mha1986128/index.html
Western Australia Mental Health Act 1996. Available at
www.mhrbwa.org.au/publications.

ERRATUM
In the January/February check unit, Figure 5 (page 9) was
incorrect.
The following are the correct pathways for faecal-reducing
substances >0.25%, and faecal pH <7.0:
YES Trial of lactose-free formula or lactase-treated breast milk
NO Trial of cows-milk-free formula or cows-milk-free
maternal diet.
The editors apologise for any confusion or inconvenience.

25

check Category 2 QI&CPD activity

Bipolar disorder
In order to qualify for 6 Category 2 points for the QI&CPD
activity associated with this unit:
read and complete the unit of check in hardcopy or
online at the gplearning website at www.gplearning.
com.au, and
log onto the gplearning website at www.gplearning.
com.au and answer the following 10 multiple choice
questions (MCQs) online
complete the online evaluation.
If you are not an RACGP member, please contact the
gplearning helpdesk on 1800 284 789 to register in the
first instance. You will be provided with a username and
password that will allow you access to the test.
The expected time to complete this activity is 3 hours.
Please note
From January 2011, there will no longer be a Category 1
activity (ALM) associated with check units. This decision
was made due to a lack of interest in this activity. The
RACGP apologises for any inconvenience caused by
this change
Do not send answers to the MCQs into the check
office. This activity can only be completed online at
www.gplearning.com.au.
If you have any queries or technical issues accessing the
test online, please contact the gplearning helpdesk on
1800 284 789.

Question 1
Wendy, age 52, presents with a 9 month history of amenorrhoea, mild
hot flushes, decreased libido, irritability and a loss of interest in her
usual activities. She also feels an increased need for sleep and has
gained 6 kg in weight. Your first step in management is to:
A. prescribe hormone replacement therapy (HRT) to treat her
menopausal symptoms
B. discuss the overlap between symptoms of depression and
menopause and suggest a trial of treatment for her depressive
symptoms
C. tell her all women have to go through menopause and it will pass
soon enough
D. prescribe both HRT and an antidepressant from the outset
E. recommend she keep a food and exercise diary and return in
3 months.
Question 2
Susie, 37 years of age, is a patient of yours who presents with acute
mania. You transfer her to hospital. Upon discharge she has been
stabilised on lithium. When treating a patient with lithium:

26

check Bipolar disorders

A. no blood tests are required before giving the first dose


B. baseline thyroid function, renal function, serum calcium
and electrocardiogram (ECG) should be established before
commencing treatment
C. serum urea and creatinine should be checked every 12 months
D. thyroid function tests should be repeated only if symptoms of
hypothyroidism develop
E. lithium toxicity usually only occurs in the first few weeks of
treatment.
Question 3
Susie is stabilised on lithium but forgets to take her tablets away
with her on a 3 month holiday. Your advice when she rings you
from interstate is:
A. resume the same dose she usually takes when she returns
from holidays
B. resume her lithium on a lower dose when she returns, then
gradually increase to her usual dose
C. do not cease her lithium abruptly due to the risk of mania. You
need to help her arrange a supply of medication
D. take a double dose for 2 days when she returns
E. have a trial of not taking her medication while she is away on
holidays as her stress levels will be lower.
Question 4
Fleur is the wife of one of your patients Brett, who is known to
be a regular cannabis user. Fleur presents concerned about her
husbands behaviour. He has recently been seen apparently talking
to himself and is frequently very agitated. She also suspects
that he may have lost his job, although he has not divulged this
information to her. He appears to be excessively confident about
his new online poker hobby. The possible explanation is:
A. he is experiencing intermittent bouts of cannabis intoxication
B. he has started using other recreational drugs such as
amphetamine
C. he may be experiencing a manic episode as part of an
emerging bipolar disorder
D. he may have an organic neurological illness
E. all of the above.
Question 5
Christie, 35 years of age, is a married woman who has recently
been diagnosed with bipolar disorder and presents with her
husband wishing to discuss her medication in the context of
wanting to start a family in the future. Concerning pharmaceutical
management of this case, you would:
A. use sodium valproate as your drug of first choice
B. advise her to continue her medication until she falls pregnant then
stop immediately as most women feel better during pregnancy

check Bipolar disorders

C. discuss the possibility of pregnancy and contraceptive options,


explaining the potential risks of unplanned pregnancy and
psychotropic medication
D. avoid discussing the possible teratogenic effects of medication as
you dont want to dissuade her from taking her medication
E. advise her that she should have a tubal ligation.

check Category 2 QI&CPD activity

Question 9
When you see Alice she appears a little vague but is oriented to time,
place and person. The nurse says she was much worse overnight.
Which of the following is true?
A. More severe delirium is associated with a greater degree of
hyperactivity
B. Vagueness in this age group is always due to dementia

Question 6
Sally comes to see you to discuss her son Marcus, age 25. Marcus
was recently diagnosed with a manic episode after presenting with
symptoms of hyperactivity, difficulty concentrating, and excessive
spending. Sally brings in an article she found on the internet about
adult attention deficit hyperactivity disorder (ADHD). She asks if this
condition could better explain Marcus symptoms. In differentiating
between ADHD and a manic episode the most useful symptom/s to
elucidate are:

C. A patients level of orientation and cognitive function are variable


over a 24 hour period

A. elation and grandiosity

A. Optimum lithium dose can change with age as creatinine


clearance decreases

B. hyperactivity and impulsivity


C. distractibility and irritability
D. talkativeness
E. insomnia and hypersomnia.
Question 7
You explain to Sally that the diagnosis of adult ADHD is controversial
and that it is unclear whether there is any relationship between ADHD
and bipolar disorder. For diagnostic purposes, which of the following
can be helpful?

D. Quiet and well behaved patients are generally cognitively intact


E. After 5 years her lithium will be well tolerated.
Question 10
You look at Alices file to see when she last had her lithium level
tested. Regarding lithium monitoring, which of the following is true?

B. Recommended serum lithium level for acute mania is


0.81.2 mmol/L
C. Toxicity occurs at serum lithium levels >1.5 mmol/L (or lower in
the elderly)
D. More frequent monitoring may be needed if other medications
change
E. All of the above.

A. Confirmation of ongoing inattentiveness and hyperactivity in the


absence of drug use
B. Review of school records
C. Interviewing the parents of adult patients
D. Awareness of any issues involving the law or relationship
breakdowns
E. All of the above.
Question 8
You are asked to review Alice Brown, age 70, a nursing home patient
with a past history of manic episodes who has been prescribed lithium
for 5 years. She has a 2 week history of a loss of appetite, social
withdrawal and vagueness. Alice was started on a new medication for
her arthritis 1 month ago. From the history, you suspect a diagnosis
of delirium and plan to review Alice as soon as possible. Which of the
following is false about delirium?
A. It is a rare condition associated with alcohol withdrawal
B. It has an acute onset, often worse at night
C. It is associated with inattention and sleep-wake cycle disturbance
D. It is an important nonspecific sign that often heralds the
development of a life threatening illness
E. It commonly causes a disturbance of consciousness.

27

notes

28

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