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Özge A, Domaç FM, Tekin N, Sünbül EA, Öksüz N, Atalar AÇ, Çallı SY, Fidan YS, Evlice A, Beştepe EE, İzci F, Küsbeci ÖY, Demirel EA, Velioğlu SK, Ungan M. One Patient, Three Providers: A Multidisciplinary Approach to Managing Common Neuropsychiatric Cases. J Clin Med 2023; 12:5754. [PMID: 37685821 PMCID: PMC10488785 DOI: 10.3390/jcm12175754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 08/27/2023] [Accepted: 08/30/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND Neuropsychiatric cases require a multidisciplinary approach for effective management. This paper presented case-based discussions on migraine, dementia, epilepsy, mood disorders, neuralgia, and psychosis from the perspectives of a family physician, neurologist, and psychiatrist. The goal was to highlight the importance of collaboration between healthcare providers in managing these complex cases. METHODS The paper was based on the proceedings of the Mediterranean Neuropsychiatry Symposium, where experts from family medicine, neurology, and psychiatry came together for comprehensive case-based discussions. The CARE framework (Case Report, Appraisal, Research, and Education) was developed to guide reporting and evaluation of case reports in clinical practice. RESULTS Six cases were presented and discussed, highlighting the importance of a multidisciplinary approach in managing neuropsychiatric cases. The cases included chronic migraine with medication overuse, memory dysfunction with language and behavioral problems, refractory epileptic seizures with subjective sensory symptoms, bipolar affective disorder with normal pressure hydrocephalus, postherpetic neuralgia in a case with bipolar affective disorder, and psychosis with recurrent attacks with the abuse of several substances. CONCLUSION A biopsychosocial multidisciplinary approach is essential for managing neuropsychiatric cases effectively on behalf of the patients and public health of the country. The CARE framework can guide the reporting and evaluation of case reports in clinical practice, ensuring that patients receive comprehensive and effective care. Healthcare providers should collaborate to provide the best possible care for patients with complex and multifaceted needs.
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Affiliation(s)
- Aynur Özge
- Department of Neurology, School of Medicine, Mersin University, Mersin 33110, Türkiye;
| | - Füsun Mayda Domaç
- Department of Neurology, Erenkoy Mental and Nervous Diseases Training and Research Hospital, University of Health Sciences, İstanbul 34668, Türkiye;
| | - Nil Tekin
- Department of Family Medicine, Izmir Faculty of Medicine, University of Health Sciences, İzmir 35330, Türkiye;
- Department of Family Medicine, Tepecik Education and Research Hospital, University of Health Sciences, İzmir 35330, Türkiye
| | - Esra Aydın Sünbül
- Department of Psychiatry, Erenköy Mental and Nervous Diseases Training and Research Hospital, University of Health Sciences, İstanbul 34668, Türkiye; (E.A.S.); (S.Y.Ç.); (Y.S.F.); (E.E.B.); (F.İ.)
| | - Nevra Öksüz
- Department of Neurology, School of Medicine, Mersin University, Mersin 33110, Türkiye;
| | - Arife Çimen Atalar
- Neurology Department, Kanuni Sultan Süleyman Education and Research Hospital, University of Health Sciences, İstanbul 34668, Türkiye;
| | - Sümeyye Yasemin Çallı
- Department of Psychiatry, Erenköy Mental and Nervous Diseases Training and Research Hospital, University of Health Sciences, İstanbul 34668, Türkiye; (E.A.S.); (S.Y.Ç.); (Y.S.F.); (E.E.B.); (F.İ.)
| | - Yağmur Sever Fidan
- Department of Psychiatry, Erenköy Mental and Nervous Diseases Training and Research Hospital, University of Health Sciences, İstanbul 34668, Türkiye; (E.A.S.); (S.Y.Ç.); (Y.S.F.); (E.E.B.); (F.İ.)
| | - Ahmet Evlice
- Department of Neurology, School of Medicine, Çukurova University, Adana 01330, Türkiye;
| | - Engin Emrem Beştepe
- Department of Psychiatry, Erenköy Mental and Nervous Diseases Training and Research Hospital, University of Health Sciences, İstanbul 34668, Türkiye; (E.A.S.); (S.Y.Ç.); (Y.S.F.); (E.E.B.); (F.İ.)
| | - Filiz İzci
- Department of Psychiatry, Erenköy Mental and Nervous Diseases Training and Research Hospital, University of Health Sciences, İstanbul 34668, Türkiye; (E.A.S.); (S.Y.Ç.); (Y.S.F.); (E.E.B.); (F.İ.)
| | - Özge Yılmaz Küsbeci
- Neurology Department, Medical Faculty, Izmir University of Economics, Izmir 35330, Türkiye;
| | - Esra Acıman Demirel
- Department of Neurology, Zonguldak Bulent Ecevit University of Medicine, Zonguldak 67100, Türkiye;
| | - Sibel K. Velioğlu
- Clinical Neurophysiology Unit, Neurology Department, Medical Faculty, Karadeniz Technical University, Trabzon 61080, Türkiye;
| | - Mehmet Ungan
- Department of Family Medicine, Medical Faculty, Ankara University, Ankara 06100, Türkiye;
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Rohilla J, Tak P, Jhanwar S, Hasan S. Primary care physician's approach for mental health impact of COVID-19. J Family Med Prim Care 2020; 9:3189-3194. [PMID: 33102268 PMCID: PMC7567264 DOI: 10.4103/jfmpc.jfmpc_513_20] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 04/25/2020] [Accepted: 06/19/2020] [Indexed: 01/31/2023] Open
Abstract
As the world struggles to control coronavirus infection with the exhausting capacity of health care systems globally, the role of primary care physician and family physician becomes more important as the first point of contact with the community. Limited availability of mental health services in India requires general practitioners to deal with psychological disorders arising due to infection outbreak and its restrictive control strategies. This article discusses what and how primary physicians can manage the psychological burden of a pandemic, and therefore, reducing the reliance on mental health specialist.
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Affiliation(s)
- Jitendra Rohilla
- Department of Psychiatry, All India Institute of Medical Science, Rishikesh, Uttarakhand, India
| | - Pinki Tak
- Department of Pharmacology, All India Institute of Medical Science, Rishikesh, Uttarakhand, India
| | - Shubham Jhanwar
- Department of Psychiatry, All India Institute of Medical Science, Rishikesh, Uttarakhand, India
| | - Shazia Hasan
- Department of Medicine, Jawaharlal Nehru Medical College, Ajmer, Rajasthan, India
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Lara DR, Bisol LW, Ottoni GL, de Carvalho HW, Banerjee D, Golshan S, Akiskal K, Akiskal HS. Validation of the "rule of three", the "red sign" and temperament as behavioral markers of bipolar spectrum disorders in a large sample. J Affect Disord 2015; 183:195-204. [PMID: 26021969 DOI: 10.1016/j.jad.2015.04.046] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2013] [Revised: 03/04/2015] [Accepted: 04/27/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND Akiskal proposed the "rule of three" for behavioral indicators with high specificity for bipolarity in patients with major depression episodes. We evaluated these distinctive behaviors in controls and subjects with major depression or bipolar disorder. METHODS data was collected in the BRAINSTEP project with questions on general behaviors, style and talents. Univariate analysis was first conducted in 36,742 subjects and confirmatory multivariate analysis in further 34,505 subjects (22% with a mood disorder). Odds ratios were calculated adjusting for age. RESULTS Univariate analysis showed that 29 behavioral markers differentiated bipolar subjects from those with unipolar depression. The most robust differences in those with bipolarity (ORs >4) were ≥3 religion changes, ≥3 marriages, cheating the partner regularly, having ≥60 lifetime sexual partners, pathological love, heavy cursing, speaking ≥3 foreign languages, having ≥2 apparent tattoos, circadian dysregulation and high debts. Most behaviors were expressed in a minority of patients (usually around 5-30%) and usually the "rule of three" was the best numerical marker to distinguish those with bipolarity. However, multivariate analysis confirmed 11 of these markers for differentiating bipolar disorder from unipolar depression (reversed circadian rhythm and high debts for both genders, ≥3 provoked car accidents and talent for poetry in men, and frequent book reading, ≥3 religion changes, ≥60 sexual partners, pathological love ≥2 times, heavy cursing and extravagant dressing style in women). LIMITATIONS Self-report data collection only. CONCLUSIONS These behavioral markers should alert the clinician to perform a thorough investigation of bipolarity in patients presenting with a depressive episode.
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Affiliation(s)
- Diogo R Lara
- Faculdade de Biociências, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Brazil.
| | - Luísa W Bisol
- Serviço de Psiquiatria, Hospital São Lucas da Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Brazil
| | - Gustavo L Ottoni
- Serviço de Psiquiatria, Hospital Presidente Vargas, Fundação Faculdade Federal de Ciências Médicas de Porto Alegre, Porto Alegre, Brazil
| | | | - Dipavo Banerjee
- International Mood Center, La Jolla, CA USA and Paris, France
| | - Shahrokh Golshan
- Department of Psychiatry, University of California at San Diego, USA
| | - Kareen Akiskal
- International Mood Center, La Jolla, CA USA and Paris, France
| | - Hagop S Akiskal
- Department of Psychiatry, University of California at San Diego, USA
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McCormick U, Murray B, McNew B. Diagnosis and treatment of patients with bipolar disorder: A review for advanced practice nurses. J Am Assoc Nurse Pract 2015; 27:530-42. [PMID: 26172568 PMCID: PMC5034840 DOI: 10.1002/2327-6924.12275] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Accepted: 04/01/2015] [Indexed: 12/19/2022]
Abstract
Purpose This review article provides an overview of the frequency, burden of illness, diagnosis, and treatment of bipolar disorder (BD) from the perspective of the advanced practice nurses (APNs). Data sources PubMed searches were conducted using the following keywords: “bipolar disorder and primary care,” restricted to dates 2000 to present; “bipolar disorder and nurse practitioner”; and “bipolar disorder and clinical nurse specialist.” Selected articles were relevant to adult outpatient care in the United States, with a prioritization of articles written by APNs or published in nursing journals. Conclusions BD has a substantial lifetime prevalence in the population at 4%. Because the manic or depressive symptoms of BD tend to be severe and recurrent over a patient's lifetime, the condition is associated with significant burden to the individual, caregivers, and society. Clinician awareness that BD may be present increases the likelihood of successful recognition and appropriate treatment. A number of pharmacological and nonpharmacological treatments are available for acute and maintenance treatments, with the prospect of achieving reduced symptom burden and increased functioning for many patients. Implications for practice Awareness of the disease burden, diagnostic issues, and management choices in BD has the potential to enhance outcome in substantial proportions of patients.
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Affiliation(s)
| | | | - Brittany McNew
- Medical Services, Centerstone of Indiana, Bloomington, Indiana
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Tang LR, Liu CH, Jing B, Ma X, Li HY, Zhang Y, Li F, Wang YP, Yang Z, Wang CY. Voxel-based morphometry study of the insular cortex in bipolar depression. Psychiatry Res 2014; 224:89-95. [PMID: 25218414 DOI: 10.1016/j.pscychresns.2014.08.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2013] [Revised: 03/11/2014] [Accepted: 08/08/2014] [Indexed: 11/30/2022]
Abstract
Bipolar depression (BD) is a common psychiatric illness characterized by deficits in emotional and cognitive processing. Abnormalities in the subregions of the insula are common findings in neuroanatomical studies of patients with bipolar disorder. However, the specific relationships between morphometric changes in specific insular subregions and the pathogenesis of BD are not clear. In this study, structural magnetic resonance imaging (MRI) was used to investigate gray matter volume abnormalities in the insular subregion in 27 patients with BD and in 27 age and sex-matched controls. Using DARTEL (diffeomorphic anatomical registration through exponentiated lie algebra) for voxel-based morphometry (VBM), we examined changes in regional gray matter volumes of the insula in patients with BD. As compared with healthy controls, the BD patients showed decreased gray matter volumes in the right posterior insula and left ventral anterior insula and increased gray matter volumes in the left dorsal anterior insula. Consistent with the emerging theory of insular interference as a contributor to emotional-cognitive dysregulation, the current findings suggest that the insular cortex may be involved in the neural substrates of BD.
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Affiliation(s)
- Li-Rong Tang
- Center of the Treatment in Depressive Disorders, Beijing Anding Hospital, Capital Medical University, Beijing 100088, China; Department of Radiology, Beijing Anding Hospital, Capital Medical University, Beijing 100088, China
| | - Chun-Hong Liu
- Department of Radiology, Beijing Anding Hospital, Capital Medical University, Beijing 100088, China; Beijing Key Laboratory of Mental Disorders, Department of Psychiatry, Beijing Anding Hospital, Capital Medical University, No. 5 Ankang Lane, Dewai Avenue, Xicheng District, Beijing 100088, China
| | - Bin Jing
- School of Biomedical Engineering, Capital Medical University, Beijing 100069, China
| | - Xin Ma
- Center of the Treatment in Depressive Disorders, Beijing Anding Hospital, Capital Medical University, Beijing 100088, China; Beijing Key Laboratory of Mental Disorders, Department of Psychiatry, Beijing Anding Hospital, Capital Medical University, No. 5 Ankang Lane, Dewai Avenue, Xicheng District, Beijing 100088, China.
| | - Hai-Yun Li
- School of Biomedical Engineering, Capital Medical University, Beijing 100069, China
| | - Yu Zhang
- Department of Radiology, Beijing Anding Hospital, Capital Medical University, Beijing 100088, China
| | - Feng Li
- Center of the Treatment in Depressive Disorders, Beijing Anding Hospital, Capital Medical University, Beijing 100088, China; Center of Schizophrenia, Beijing Institute for Brain Disorders, Laboratory of Brain Disorders, Capital Medical University, Ministry of Science and Technology, Beijing 100088, China
| | - Yu-Ping Wang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing 100053, China; Beijing Key Laboratory of Neuromodulation, Capital Medical University, Beijing 100053, China
| | - Zhi Yang
- Key Laboratory of Behavioral Science, Institute of Psychology, Chinese Academy of Sciences, Beijing 100101, China.
| | - Chuan-Yue Wang
- Beijing Key Laboratory of Mental Disorders, Department of Psychiatry, Beijing Anding Hospital, Capital Medical University, No. 5 Ankang Lane, Dewai Avenue, Xicheng District, Beijing 100088, China; Center of Schizophrenia, Beijing Institute for Brain Disorders, Laboratory of Brain Disorders, Capital Medical University, Ministry of Science and Technology, Beijing 100088, China
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Abstract
Primary care providers (PCPs) are frequently responsible for the pharmacologic management of mood disorders, and the PCP is often an important member of the clinical team in the management of bipolar disorder and schizophrenia. Not only is a good understanding of psychopharmacology important for the effective treatment of psychiatric disease, it is also necessary for patient safety. Clinicians should understand the side effects and the medication interactions associated with psychotropic medications. This article reviews mechanisms of action, indications, dosing, side effects, medication interactions, and general management considerations for common medications used to treat psychiatric conditions encountered in the primary care setting.
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Affiliation(s)
- L Renata Thronson
- Division of General Internal Medicine, Department of Medicine, Adult Medicine Clinic, Harborview Medical Center, University of Washington School of Medicine, 325 9th Avenue, Seattle, WA 98104, USA.
| | - Genevieve L Pagalilauan
- Department of Medicine, Division of General Internal Medicine, Roosevelt General Internal Medicine Clinic, University of Washington Medical Center, 4245 Roosevelt Way North East, Seattle, WA 98105
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Culpepper L. The diagnosis and treatment of bipolar disorder: decision-making in primary care. Prim Care Companion CNS Disord 2014; 16:PCC.13r01609. [PMID: 25317368 PMCID: PMC4195640 DOI: 10.4088/pcc.13r01609] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2013] [Accepted: 01/27/2014] [Indexed: 01/26/2023] Open
Abstract
Bipolar disorder is a chronic episodic illness, characterized by recurrent episodes of manic or depressive symptoms. Patients with bipolar disorder frequently present first to primary care, but the diversity of the potential symptoms and a low index of suspicion among physicians can lead to misdiagnosis in many patients. Frequently, co-occurring psychiatric and medical conditions further complicate the differential diagnosis. A thorough diagnostic evaluation at clinical interview, combined with supportive case-finding tools, is essential to reach an accurate diagnosis. When treating bipolar patients, the primary care physician has an integral role in coordinating the multidisciplinary network. Pharmacologic treatment underpins both short- and long-term management of bipolar disorder. Maintenance treatment to prevent relapse is frequently founded on the same pharmacologic approaches that were effective in treating the acute symptoms. Regardless of the treatment approach that is selected, monitoring over the long term is essential to ensure continued symptom relief, functioning, safety, adherence, and general medical health. This article describes key decision-making steps in the management of bipolar disorder from the primary care perspective: from initial clinical suspicion to confirmation of the diagnosis to decision-making in acute and longer-term management and the importance of patient monitoring.
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Affiliation(s)
- Larry Culpepper
- Department of Family Medicine, Boston University Medical Center, Boston, Massachusetts
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Ketter TA. Strategies for monitoring outcomes in patients with bipolar disorder. PRIMARY CARE COMPANION TO THE JOURNAL OF CLINICAL PSYCHIATRY 2011; 12:10-6. [PMID: 20628501 DOI: 10.4088/pcc.9064su1c.02] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Practical strategies are available for primary care physicians to monitor psychiatric and medical outcomes as well as treatment adherence in patients with bipolar disorder. Current depressive symptoms can be assessed with tools like the 9-item Patient Health Questionnaire or Beck Depression Inventory. Lifetime presence or absence of manic or hypomanic symptoms can be assessed using the Mood Disorder Questionnaire (MDQ). These measures can be completed quickly by patients prior to appointments. Sensitivity of such ratings, particularly the MDQ, can be increased by having a significant other also rate the patient. Clinicians should also screen mood disorder patients for psychiatric comorbidities that are common in this population such as anxiety and substance use disorders. While patients with bipolar disorder may commonly be nonadherent with prescribed medication regimens, strategies that can help include having frank discussions with the patient, selecting medication collaboratively, adding psychotherapy with a psychoeducation element, monitoring appointment-keeping, using patient self-reports of medication-taking, enlisting the aid of significant others, and measuring plasma drug levels. Medical monitoring is needed to assess the safety and tolerability of psychotropic medications. All of the approved medications for bipolar disorder have at least 1 boxed warning for serious side effects, but are also associated with other common management-limiting side effects such as sedation, tremor, unsteadiness, restlessness, nausea, vomiting, diarrhea, constipation, weight gain, and metabolic problems. Routine monitoring is particularly needed for obesity, metabolic syndrome, and cardiovascular disorders, which lead to high rates of medical morbidity and mortality in patients with bipolar disorder. Monitoring protocols such as the one recommended by the American Diabetes Association for patients taking second-generation antipsychotics can be used for regular assessment.
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Affiliation(s)
- Terence A Ketter
- Department of Psychiatry and Behavioral Sciences, and the Bipolar Disorders Clinic, Stanford University School of Medicine, Stanford, California
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