Abdullah Al-Subaie F.R.C.P (C)Professor of Psychiatry

• Cancer• Epilepsy• Fahr disease• AIDS• Medications (eg, antidepressants,

baclofen, bromide, bromocriptine, captopril, cimetidine, corticosteroids, cyclosporine, disulfiram, hydralazine, isoniazid, levodopa, methylphenidate, metrizamide, procarbazine, procyclidine)

Idiopathic Basal Ganglia Calcification

-------personality and/or

behavior, to psychosis and

dementia

Circadian rhythm desynchronization Cyclothymic disorder Oppositional defiant disorder (in children) Substance abuse disorders (eg, with

alcohol, amphetamines, cocaine, hallucinogens, opiates)

1. The basic principle remains, "do not miss a treatable medical cause for the mental status.“

2. The condition necessitates use of a number of medications that require certain body systems to be working properly.

3. Because bipolar illness is a lifelong disorder, performing certain baseline studies is important.

4. A number of infections, especially chronic infections, can produce a presentation of depression in the patient.

A complete blood count (CBC) with differential  To rule out anemia as a cause of depression. Treatment, with certain anticonvulsants, may

depress the bone marrow-hence the need to check the red blood cell (RBC) and white blood cell (WBC).

Lithium may cause a reversible increase in the WBC count.

Erythrocyte sedimentation rate  To look for any underlying disease process

such a lupus or an infection.

Fasting glucose Atypical antipsychotics have been associated

with weight gain and problems with blood glucose regulation in patients with diabetes.

Electrolytes Hyponatremia can manifest as a depression. Treatment with lithium can lead to renal

problems and electrolyte problems. Low sodium levels can lead to higher lithium

levels and lithium toxicity. Lithium toxicity can lead to renal impairment.

• Calcium– Hyperparathyroidism, produces depression.– Certain antidepressants, such as nortriptyline,

affect the heart.

• Proteins– Low serum protein levels in depressed

patients may be a result of not eating. – Low serum protein levels increase the

availability of certain medications because these drugs have less protein to which to bind.

• Thyroid hormones– To rule out hyperthyroidism (mania) and

hypothyroidism (depression). – Treatment with lithium can cause

hypothyroidism, which may also contribute to the rapid cycling of mood.

• Creatinine and blood urea nitrogen– Kidney failure can present as depression. – Treatment with lithium can affect urinary

clearances, and serum creatinine and blood urea nitrogen (BUN) levels can increase.

Substance and Alcohol Screening Substance abuse can present as either mania

or depression. A number of patients with bipolar affective

disorder also have a drug or alcohol addiction. Performing a substance screen helps make this dual diagnosis

• Other Laboratory Tests– Urine copper level testing is used to rule out Wilson

disease, which produces mental changes. This disease is a rare condition that is easily missed.

• Antinuclear antibody testing is used to rule out lupus.

• An HIV test because AIDS causes changes in mental status, including dementia and depression.

• A VDRL test may be indicated. Syphilis, especially in its later stage, alters mental status.

• Magnetic Resonance Imaging– The total value of performing magnetic resonance

imaging (MRI) in a patient with bipolar disorder remains unclear; however,

– To establishes a baseline in such a chronic illness.– Some investigators report that patients with

mania have hyperintensity in their temporal lobes.

• Electrocardiography– Many antidepressants, Lithtium and some of the

antipsychotics, can affect the heart and cause conduction problems.

• Electroencephalography

– EEG provides a baseline and helps rule out any neurologic problems such as seizure disorder and brain tumor.

– In electroconvulsive therapy (ECT), EEG monitoring during ECT is used to detect occurrence and duration of seizure.

– Some EEG findings may indicate anticonvulsant effectiveness. Specifically, to valproate.

– Some patients may have seizures when on medications, especially antidepressants. In addition, lithium can cause diffuse slowing.

• The treatment is directly related to the phase of the episode and the severity of that phase.

• Most patients recover from the first manic episode, but their course beyond that is variable.

• All patients with bipolar disorder need education, outpatient monitoring for both medications and psychotherapy.

• The schedule must be regular, with great

flexibility if they need extra sessions.

• ECT may be needed but no surgical care is indicated for bipolar disorder

1. Danger to self A depressed patient may have suicidal

ideation, attempts or plans. A person who is depressed enough to not eat

might be at risk of death. A person in extreme mania who foregoes

sleep or food may be in a state of serious exhaustion.

2. Danger to others A patient experiencing a severe depression

may believe the world was so bleak that he planns to kill his children to spare them from the world’s misery.

A delusional patient having a manic episode may believes everyone was against him; he searches for a rifle in order to defend himself and to get them before they got him.

3. Total inability to function– Leaving such a person alone would be

dangerous and not therapeutic.

4. Total loss of control1. The patient’s behaviors may go totally out of

control to harm themselves & others and may destroy their career & social position.

5. Medical conditions that warrant medication monitoring Such as cardiac and renal conditions where

the effects of the psychotropic medications can be monitored and observed closely.

1. Look at areas of stress and find ways to handle them: The stresses can stem from family or work, This is a form of psychotherapy.

2. Monitor and support the medication: Patients are ambivalent about their medications and they resent that they need them. The job is to address their feelings and allow them to continue with the medications.

3. Develop and maintain the therapeutic alliance: Over time, the strength of the alliance helps keep the patient’s symptoms at a minimum and helps the patient remain in the community.

4. Provide education (see Patient Education): Both the patient and the family need to be aware of the dangers of substance abuse, the situations that would lead to relapse, and the essential role of medications.

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Appropriate medication depends on the stage the patient is experiencing.

A number of drugs are indicated for an acute manic episode, primarily the antipsychotics, valproate, and benzodiazepines (eg, lorazepam, clonazepam)

The choice of agent depends on the presence of symptoms such as psychotic symptoms, agitation, aggression, and sleep disturbance.

• Depressed Patient1. In a patient with bipolar depression who is not

on a mood-stabilizing agent, options include quetiapine or olanzapine, with carbamazepine and lamotrigine as alternatives. However, most clinicians use antidepressants and an antimanic agent in combination.

2. If the patient is already optimally treated with

a mood-stabilizing agent such as lithium, an option would be lamotrigine.

2-Manic phase: Lithium is the drug commonly used for

prophylaxis and treatment of manic episodes.

S\E , hypothyroidism, hyperparathyroidism, and weight gain ,renal insufficiency, GE.

Antipsychotic is also useful for mania & mood stabilization.

According to a multiple treatments meta-analysis of treatments for acute mania, haloperidol, risperidone, and olanzapine are the most efficacious treatments.

Uses: MDD. Bipolar dis. Schizophrenia. Additional uses:

TDParkinsonNMSTreatment resistant OCDChronic painCatatonia.

Hx , physical exam., CBC , TFT , X-ray & ECG

Additional Ix to r\o any brain lesion.

What to use for procedure :What to use for procedure : Atropine ( reduces secretions)Atropine ( reduces secretions) General anesthesia.General anesthesia. Succinylcholine ( ms relaxation)Succinylcholine ( ms relaxation) Oxygen.Oxygen. Place electrode in unilateral NON-Place electrode in unilateral NON-

DOMINANT part.DOMINANT part.

Seizure at least for 25 seconds. If not induced : hyperventilation

S\ES\E HeadacheHeadache Post ictal delirium.Post ictal delirium. Memory loss.Memory loss.

Absolute :None

Relative: Recent CVABrain tumorHTNRecent MISever osteoporosis\osteoarthitis

Lithium ---with ECT as it causes delirium

Benzodiazipines---prevents seizure.

No. of sessions:3-12 for MDD10-20 for bipolar mania.1-4 for catatonia