(Please note that this is an Initial evaluation)

DATE: November 1998

Case I: Initial Presentation:

MP is a 42 y/o male brought to the State Hospital after being arrested by police for obstructing traffic and grand theft auto. Over the past 2 weeks, MP apparently began parking approximately 20 cars the street in front of his sister’s home and subsequently blocking traffic. MP stated that he is a "used car salesman" and has "dealerships all over the country". MP’s sister states that MP has not been sleeping for the past four days. He has not been taking his medications over the past 2-3 weeks. MP is cooperative in the interview. Mental status examination indicates that MP is alert and orientated. He is dressed in a green plaid leisure suit with a bowtie. His mood is elevated with grandiose delusions. MP appears easily distractible with pressured thoughts and speech. He denies auditory or visual hallucinations. He denies depression symptoms and denies suicidal ideations. MP has poor insight into his illness and demonstrates poor judgement. Physical assessment is unremarkable. Blood pressure 150/90, pulse 100 bpm. Labs: Lithium level 0.1mEq/L, Urine toxicology: benzodiazepines, Thyroid function WNL, BUN 20, Serum Creatinine 1.0, Chemistry, urinalysis and hematology WNL, and Syphilis test negative.

Axis I: Bipolar Affective Disorder, Manic

Axis II: deferred

Axis III: Hypertension, polyuria, hypothyroidism

Axis IV: Severe, the patient has recently (3 months ago) lost his job at an accounting firm. Divorced November 1997. Three children living - wife has full custody.

Axis V: GAF - 40

 Last admission was on September 1998 (Two months ago)

 Section A: Please refer to the UIC Department of Psychiatry Pre-evaluation.

1. Why did the patient describe having a seizure on haloperidol?

Answer:

MP probably had a dystonic reaction from the haloperidol.

2. What could be some reasons for MP’s non-compliance with medications? What are some ways to address the non-compliance?

Answer:

MP could be non-compliant to his medications for a variety of reasons. Your Job would be to try to find out the main reasons. The possibilities are many. MP’s medication regimen is very complicated with very frequent dosing of lithium, risperdal, and Clonazepam. It would be possible to change all the medications to a twice a day dosing frequency. The medication side-effects would have to be addressed. The patient’s insurance situation may prevent the patient from obtaining medications; especially since he is currently unemployed. Finally, the most difficult aspect to deal with is the patient’s lack of insight. Many times a patient may deny having a psychiatric illness. Insight tends over time (3 –6 weeks) to improve if the patient is convinced to restart the medications.

Section B; Part I: Past Psychiatric Medical Record Summary

1. MP was hospitalized in May 1978 and diagnosed with Schizophrenia, Why might a person with bipolar affective disorder be diagnosed with Schizphrenia?

Answer:

MP becomes very delusional and psychotic during his manic episodes and can be mistaken for schizophrenia. It is important to look at the patient’s past history to understand his highest level of functioning. Usually patients with schizophrenia will have greater impairment in psychosocial function overall.

2. MP’s course of illness has become worse over the past year. True/False TRUE

Please Explain:

Patient was initially stabilized on Lithium for 9 years without hospitalization (1985 – 1994). Then duration of hospital-free months dropped to 2 – 3 months. The patient had 4 manic and 1 depressive relapse within one year. Please note the increase in MP’s need for a combination of psychiatric medications as the illness progressed.

3. Which term would best describe MP’s psychiatric illness?

A. Schizoaffective Disorder

B. Bipolar I Disorder, Manic, Rapid Cycler B. Four manic/depressive episodes in 12 months would be defined as Rapid Cycling.

C. Bipolar II Disorder, Rapid Cycler

D. Cyclothymic Disorder

E. Mixed Bipolar Disorder

 Section B; Part II: Past Psychiatric Medical Record Summary

4. Which of the following can cause MP to have a worsening course of illness?

A. Antidepressant use (i.e. fluoxetine and paroxetine use)

B. Alcohol abuse

C. Risperidone

D. Medication Noncompliance

E. All of the above are correct : This is true, antidepressants should be used cautiously in patients with bipolar affective disorder and discontinued 2-3 months after depressive symptoms have resolved if possible. Risperidone has been implicated in worsten manic symptoms in some patients. The clinician must observe for increasing manic-symptoms with risperidone. Alcoholism and polysubstance abuse is implicated in more refractory cases of bipolar illness. Polysubstance abuse alone can worsen the patient’s course of illness.

5. What would be the recommendations to treat the initial agitated symptoms?

A. Haloperidol
B. Lorazepam : Start the patient back on Lorazepam for several reasons: avoid withdrawal symptoms (ETOH abuse and past clonazepam use. Patient is sensitive to EPS from haloperdol. Triazolam (Halcion) is a hypnotic agent.
C. Triazolam

6. What baseline laboratory information would be important prior to initiating medication therapy?

A. CBC with Differential

B. Chemistry Profile

C. Urinalysis and Drug screen

D. Thyroid profile

E. All of the above Depakote/thrombocytopenia. Carbamazepine/leukopenia, Lithium/leukocytosis Baseline liver function tests are important for lamotrigine, depakote and carbamazepine. Electrolytes (Sodium)and urinalysis for lithium and carbamazepine. BUN and Serum Creatinine for lithium and gabapentin. Thyroid profile baseline for lithium.

7. What would be the recommendations for the treatment of the patient’s acute manic symptoms?

A. Restart Lithium 600mg tid

B. Start Gabapentin 300mg bid and titrate up to 1800mg/day in divided doses.

C. Start Divalproex Sodium (20mg/kg): 500mg po tid.:Lithium is causing side-effects (polyuria). Lithium is not effective in rapid cycling. Limited data with Gabapentin alone…May be useful as adjunctive agent with Olanzapine or Divalproex together. Divalproex may be the best choice (carbamazepine could be an alternative choice). Lamotrigine needs to be titrated slowly to avoid rash. Lamotrigine would be selected if patient fails Divalproex.

Section B; Part III:

9. MP has been stabilized on a mood-stabilizer for approximately 2 weeks. Describe (1) which laboratory tests would be important for monitoring and (2) when they should be obtained and (3) how often for the following medications:

Lithium: baseline then q6-12mo. CBC, UA, Chemistry, Thyroid, Urine tox, HCG (women), trough serum level 12 hours after evening dose on day 3-4, then weekly x 3 weeks, then repeat every 4 – 6 months if stable.
Carbamazepine: baseline then q6-12mo. CBC, UA, Chemistry, Thyroid, Urine tox, HCG (women), trough serum level 12 hours after evening dose on day 4-5, then repeat in 3-4 weeks (monitor Autoinduction: serum levels may decrease and dosage may need to be increased), then repeat every 4 – 6 months if stable.
Divalproex Sodium: baseline then q6-12mo. CBC, UA, Chemistry, Thyroid, Urine tox, HCG (women), trough serum level 12 hours after evening dose on day 4-5, then repeat in 3-4 weeks, then repeat every 6 – 12 months if stable.
Lamotrigine: baseline then q6-12mo. CBC, UA, Chemistry, Thyroid, Urine tox, HCG (women)
Gabapentin: baseline then q6-12mo. CBC, UA, Chemistry, Thyroid, Urine tox, HCG (women)

10. MP has a partial response to divalproex Sodium and the psychiatrist wants to add Lamotrigine. What special precautions and changes should be made to MP’s medication management?

Lamotrigine’s half-life may increase to ~58 hours if divalproex is added. Dose lamotrigine 25mg every other day for 2 wks, then increase by 25-50mg/day every 1-2 weeks up to 100-150mg/day in two divided doses.

Section B; Part IV:

Two months (September – November) prior to current presentation:

Since April, 1985 when MP was started on Lithium, he has complained of polydipsia/polyuria. During September he was started on hydrochorothiazide to treat the polyuria caused by lithium. However, he began to have the "shakes" and then stopped all of the medications after one week.

Section B; Part IV: Questions:

1. Lithium can cause which of the following side-effect(s)? Describe how to manage the lithium side effect(s) and the mechanisms involved.

A. Diarrhea

B. Tremor

C. Hypothyroidism

D. Polyuria

E. All of the above are correct: Tremor: try to decrease dose however this may be difficult if patient is unstable, Other alternatives depending on the severity include propranolol 20mg po bid. Hypothyroidism: this is a fairly rare event 0.2% however can be managed by treating with levothyroxine. Usually patient is followed by an endocrinologist or internist. Polyuria: also a rare event usually associated with polydipsia, the mechanism appears to be lithiums inhibition of ADH and thus decreasing renal concentrating ability. Hydrochlorothiazide is sometimes used as treatment because it blocks distal sodium reabsorption and increases the urine osmolarity in the tubules (compensating for lack of concentrating ability) and thus there is a decrease in urine volume.

2. Which medication(s) is/are taken by MP that can interact with lithium? How can adverse reactions be avoided in this case of MP?
Explain:

A. Lisinopril (Ace-Inhibitor) The Lisinopril was started and the lithium dose was decreased accordingly.

B. Hydrochlorothiazide (HCTZ) Thiazide diuretics block reabsorbtion of sodium distally causing a compensatory increase in Lithium reabsorpton in the proximal tubules. To avoid this problem consider switching to a Loop diuretic (Furosemide: although monitor closely) or acetazolamide or spironolactone which will actually increase lithium clearance.

3. Why did MP complain of the "Shakes" after his hospitalization in Sept 1998?
Explain:
The patients Lithium level was 1.1mEq/L during the hospitalization in September. However, MP was started on HCTZ for lithium-induced polyuria and HCTZ can elevate Lithium levels.

4. What are the symptoms and lithium serum levels associated with Lithium Toxicity?
< 2mEq/L NVD, tremor, drowsiness
2-3mEq/L ataxia, blurred vision, vertigo, slurred speech, hypertonia
>3mEq/L seizures, arrhythmias, hypotension, coma

5. Which factors and other medications can cause elevated lithium levels and also decrease lithium levels during treatment?
NSAIDS, Thiazide Diuretics, Ace-Inhibitors, Calcium Channel blockers, Dehydration

6. Why was MP started on levothyroxine during his treatment?
Lithium can inhibit T3/T4 production and cause a hypothyroid state.