Psychiatric Associates

Bipolar Disorder

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What is Bipolar Disorder?
 
       Bipolar Disorder, also known as Manic-Depressive Disorder, is a brain disorder that causes unusual shifts in mood and energy and impairs the sufferer's ability to carry out day-to-day tasks. Symptoms of Bipolar Disorder can be severe. They are different from the normal ups and downs that everyone goes through from time to time. Bipolar Disorder can result in damaged relationships, poor job or school performance, and even suicide. But Bipolar Disorder can be treated, and people with this illness can lead full and productive lives.
 
       Bipolar Disorder often develops in a person's late teens or early adult years. At least half of all cases start before age 25. Some people have their first symptoms during childhood, while others don't develop symptoms until later in life.
 
       Bipolar Disorder isn't easy to spot when it starts. The symptoms may seem like separate problems rather than parts of the same larger problem. Some people, unfortunately, suffer for years before they are properly diagnosed and treated. Like diabetes or heart disease, Bipolar Disorder is a long-term illness that must be carefully managed throughout a person's life. It tends to worsen if it's not treated. Over time, a person with Bipolar Disorder may experience more frequent and more severe episodes than when the Disorder first appeared. Delays in getting the right diagnosis and treatment make a person more likely to experience personal, social, and work-related problems. Proper diagnosis and treatment, in contrast, helps a person with the Disorder lead a healthy and productive life. In most cases, treatment can help reduce the frequency and severity of episodes.
 
One Person's Story:
 
       Four years ago James found out that he has Bipolar Disorder. He knows that it's a serious illness, but he was relieved when he found out because he'd had symptoms for years but no one had known what was wrong. Now he's getting treatment and feeling better.
 
       James often felt really sad. As a kid, he skipped school or stayed in bed all day when he was down. At other times he felt really happy, talked fast, and felt like he could do anything. James lived like this for a long time, but things changed last year when his job got very stressful. He felt like he was having more "up" and "down" times. His wife and friends wanted to know what was wrong, but he just said everything was fine and told them to leave him alone. A few weeks later, though, James couldn't get out of bed and felt awful day after day. His wife finally took him to his Primary Care Provider (PCP), who sent him to a Psychiatrist for an evaluation. He talked to the Psychiatrist about how he was feeling, and even James could see that his ups and downs were causing him significant problems. The Psychiatrist diagnosed James with Bipolar Disorder, prescribed medication for him, and referred him to a mental health provider for psychotherapy. Now James takes medication and sees his therapist regularly. Getting help was hard at first, and took some effort, but now he's back at work. His mood swings aren't as extreme, and he's having fun again with his wife and friends.
 
What are the symptoms of Bipolar Disorder?

       People with Bipolar Disorder experience unusually intense emotional states that occur in distinct periods referred to as "mood episodes." These include Manic Episodes, Hypomanic Episodes, and Depressive Episodes. Manic Episodes are characterized by one or more of the following:

  • elevated mood (periods of heightened or excessive confidence, joy, cheerfulness, or euphoria, often with an infectious quality);
  • expansive mood (expression of feelings without restraint, frequently with an overestimation of the person's significance or importance); or
  • irritable mood (periods of being easily annoyed or quickly provoked to anger, especially when thwarted or told no). 

       In addition, people experiencing a Manic Episode also experience three or more (four or more if the mood is irritability) of the following:

  • inflated self-esteem or grandiosity;
  • a decreased need for sleep (feeling rested after only three hours of sleep);
  • being more talkative than usual or feeling a pressure to keep talking;
  • flight of ideas (constant rapid shifting from one idea to another) or the subjective experience that your thoughts are racing;
  • distractibility (your attention being too easily drawn to unimportant or irrelevant things around you);
  • increased goal-directed activity (social, work, school, or sexual behaviors) or psychomotor agitation (mental and physical excitation or restlessness); or
  • excessive involvement in pleasurable activities that have a high potential for painful consequences (engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments).

       Hypomanic Episodes are essentially the same as Manic Episodes, but don't last as long and aren't as incapacitating or debilitating to the person.

       Depressive Episodes are characterized by one or both of the following two symptoms:

  • depressed mood (feeling sad, blue, down in the dumps, empty, helpless, or hopeless); and
  • anhedonia (an inability to experience pleasure, enjoyment, or happiness).

       In addition, people experiencing a Depressive Episode also experience at least three of the following symptoms nearly every day:

  • decreased or increased appetite or significant weight loss or gain;
  • difficulty falling asleep or staying asleep, or waking up too early;
  • sleeping much longer at night, napping during the day, or fighting off falling asleep during the day;
  • mental and physical excitation, racing thoughts, flight of ideas, or restlessness;
  • thinking and moving as if you’re in slow motion;
  • fatigue or loss of energy;
  • feelings of worthlessness or guilt;
  • difficulty thinking, concentrating, or deciding; and/or
  • recurrent thoughts of death or suicide, a suicide plan, or a suicide attempt.

What types of Bipolar Disorder are there?

       There are four types of Bipolar Disorder: Bipolar I Disorder, Bipolar II Disorder, Cyclothymic Disorder (also called Cyclothymia), and Bipolar Disorder Not Otherwise Specified (NOS).

  • Bipolar I Disorder is characterized by Manic or Mixed (manic and depressed) Episodes that last at least seven days, or by manic symptoms that are so severe that the person needs to be hospitalized immediately. Usually the person also experiences Depressive Episodes lasting at least two weeks. The symptoms of mania and/or depression have to be a major change from the person's normal behavior.
  • Bipolar II Disorder is characterized by a pattern of Depressive Episodes alternating with Hypomanic Episodes, but doesn't feature any Manic or Mixed Episodes.
  • Cyclothymic Disorder is a mild form of Bipolar Disorder characterized by Hypomanic Episodes that alternate with mild Depressive Episodes for at least two years and don't meet the diagnostic requirements for any other type of Bipolar Disorder.  
  • Bipolar Disorder NOS is characterized by symptoms of Bipolar Disorder that don't meet the diagnostic requirements for either Bipolar I Disorder or Bipolar II Disorder. For example, they may not last long enough or the person may not have enough of them. The symptoms must be a major change from the person's normal behavior, however.
       Some people experience Rapid-Cycling Bipolar Disorder. This is characterized by four or more Depressive Episodes, Manic Episodes, Hypomanic  Episodes, or Mixed Episodes within a 12-month period. Some people experience more than one episode in a week, or even in a day. Rapid-Cycling Bipolar Disorder seems to be more common in people who have severe Bipolar Disorder and may be more common in people who have their first episode at a younger age. One study found that people with Rapid-Cycling Bipolar Disorder had their first episode about four years earlier than average, during mid- to late-teen years, than people without Rapid-Cycling Bipolar Disorder. Rapid-Cycling Bipolar Disorder seems to affect more women than men. 
 
What are the symptoms of Bipolar Disorder in Children and Adolescents?
 
       Children and adolescents with Bipolar Disorder go through unusual mood changes. Sometimes they feel very happy or "up" and are much more active than usual, indicating that they're experiencing a Manic Episode. Sometimes, though, they feel sad and "down" and are much less active than usual, indicating that they're experiencing a Depressive Episode.
 
       Bipolar Disorder isn't the same as the normal ups and downs that every kid goes through. Bipolar symptoms are more powerful than that. They can make it hard for a kid to do well in school or to get along with friends and family members, and can even be dangerous. Some kids with Bipolar Disorder try to hurt themselves, attempt suicide, or engage in destructive or even criminal behaviors. Children and adolescents with Bipolar Disorder should get treatment. With help, they can manage their symptoms and lead successful lives.
 
       A Manic Episode in children and adolescents is characterized by:
  • feeling very happy or acting silly in a way that's unusual;
  • having a short temper;
  • talking really fast about a lot of different things;
  • having trouble sleeping but not feeling tired;
  • having trouble staying focused;
  • talking and thinking about sex more often;
  • or doing risky things. 
       A Depressive Episode in children and adolescents is characterized by:
  • feeling very sad;
  • complaining about pain a lot, like stomachaches and headaches;
  • sleeping too little or too much;
  • feeling guilty or worthless;
  • eating too little or too much;
  • having little energy;
  • having no interest in doing fun activities;
  • and thinking or talking about death or suicide.

Click HERE for an in-depth article on "Bipolar Disorder in Children and Adolescents" by Dr. Hranilovich.

What disorders often accompany Bipolar Disorder?

       Substance abuse is very common among people with Bipolar Disorder, but the reasons for this aren't clear. Some people with Bipolar Disorder may try to treat their symptoms with alcohol or drugs. Substance abuse may trigger or prolong an episode of Bipolar Disorder, while the behavioral control problems associated with mania can result in a person abusing substances. 

       Anxiety Disorders such as Posttraumatic Stress Disorder (PTSD) and Social Phobia often accompany Bipolar Disorder. Bipolar Disorder is often accompanied by Attention-Deficit/Hyperactivity Disorder (ADHD), which has some symptoms that overlap with those of Bipolar Disorder, such as restlessness and being easily distracted. 

       People with Bipolar Disorder are at higher risk for thyroid disease, migraine headaches, heart disease, diabetes, obesity, and other physical illnesses. These illnesses may cause symptoms of mania or depression. They may also result from medications used to treat Bipolar Disorder. Other illnesses can make Bipolar Disorder hard to diagnose and treat. Someone with Bipolar Disorder should monitor his physical and mental health. If a symptom does not get better with treatment, he should inform his doctor.

       Depression commonly occurs with medical conditions, especially in the elderly. When depression and medical conditions accompany each other, it's necessary to try to determine whether either the underlying medical condition or any drugs that the person is taking for the medical condition are causing the depression. Many studies indicate that treatment of an accompanying Major Depressive Disorder can improve the course of an underlying medical disorder, even cancer.

What causes Bipolar Disorder?

       Research has determined some possible causes of Bipolar Disorder. Most researchers agree that there is no single cause. Rather, many factors likely act together to produce the disorder or to increase the risk of someone having it. 

       Genetics: Bipolar Disorder tends to run in families, so researchers are looking for genes that may increase a person's chance of developing the disorder. Genes are the "building-blocks" of heredity. They help control how the body and brain work and grow. Genes are contained inside the cells that are passed down from parents to children. Children with a parent or sibling who has Bipolar Disorder are four to six times more likely to develop the disorder, compared to children who don't have a family history of Bipolar Disorder.

       Genetic research on Bipolar Disorder is being helped by advances in technology. This type of research is now much quicker and more far-reaching than in the past. One example is the launch of the Bipolar Disorder Phenome Database, funded in part by NIMH. Using the database, researchers will be able to link visible signs of the disorder with the genes that may influence them. So far, researchers using this database found that most people with Bipolar Disorder had:

  • missed work because of the disorder;
  • other illnesses at the same time, especially Alcohol and/or Substance Abuse and Panic Disorders;
  • and had been treated or hospitalized for Bipolar Disorder.
       The researchers also identified certain traits that appeared to run in families, including:
  • a history of psychiatric hospitalizations;
  • co-occurring Obsessive-Compulsive Disorder (OCD);
  • similar age at first Manic Episode;
  • and similar numbers and frequencies of Manic Episodes.
       Researchers continue to study these traits, which may help them find the genes that cause Bipolar Disorder some day.
 
       But genes aren't the only risk factor for Bipolar Disorder. Studies of identical twins have shown that the twin of a person with Bipolar Disorder does not always develop the disorder. This is important because identical twins share all of the same genes. The study results suggest that factors besides genes are also at work in Bipolar Disorder. It's likely that many different genes and a person's environment are involved. However, researchers don't yet fully understand how these factors interact to cause Bipolar Disorder.
 
       Brain structure and functioning: Brain-imaging studies are helping researchers learn what happens in the brain of a person with Bipolar Disorder. Newer brain-imaging tools, such as functional magnetic resonance imaging (fMRI) and positron-emission tomography (PET) scans allow researchers to take pictures of the living brain at work. These tools help researchers study the brain's structure and activity.
 
       Some imaging studies show how the brains of people with Bipolar Disorder may differ from the brains of healthy people or people with other mental disorders. For example, one study using fMRI found that the pattern of brain development in children with Bipolar Disorder was similar to that in children with "multi-dimensional impairment," a disorder that causes symptoms that overlap somewhat with Bipolar Disorder and Schizophrenia. This suggests that the common pattern of brain development may be linked to general risk for unstable moods.
 
       Learning more about these differences, along with information gained from genetic studies, helps researchers better understand Bipolar Disorder. Someday researchers may be able to predict which types of treatment will work most effectively. They may even find ways to prevent Bipolar Disorder.
 
How is Bipolar Disorder diagnosed?

       Even the most severe Bipolar Disorder is highly treatable. As is true of most medical and psychological disorders, the earlier that treatment begins the more effective it is and the higher the likelihood that recurrences can be prevented.

       The first step toward getting help is to see your Primary Care Provider (PCP), the medical provider whom you see for other disorders. Certain medical conditions, such as a stroke or a brain tumor, can cause the same symptoms as Bipolar Disorder. Your PCP can rule out these conditions by conducting a physical examination, asking questions, and/or ordering lab tests, including brain scans. If medical conditions can be ruled out, your PCP will then either perform a brief mental status exam or refer you to a mental health professional who's familiar with Bipolar Disorder for further evaluation and treatment.

       A mental health professional will conduct a complete diagnostic evaluation, including a discussion of any family history of Bipolar Disorder and other psychological disorders and a complete history of symptoms. This history will include when your Bipolar Disorder started; how long you've been experiencing mania and/or depression; how severe you're mania and/or depression are; whether or not you've experienced Bipolar Disorder before; if so whether or not you received treatment and how successful that treatment was; whether or not alcohol and/or substance abuse are involved; and whether or not you feel suicidal and/or are planning to harm or kill yourself. The mental health professional may also talk to your close relatives or spouse and get their observations of your symptoms and possibly additional details about family history.

       People with Bipolar Disorder are more likely to seek help when they're depressed than when they're manic or hypomanic. Therefore, a careful history is needed to assure that Bipolar Disorder isn't mistakenly diagnosed as Major Depressive Disorder, also called Unipolar Depression. Unlike people with Bipolar Disorder, people who have Major Depressive Disorder don't experience mania. Whenever possible, previous records and input from family members and friends should also be included in the medical history.

How is Bipolar Disorder treated?

       At present, there's no cure for Bipolar Disorder. But proper treatment helps most people with Bipolar Disorder gain better control of their mood swings and related symptoms. This is also true even for people with the most severe forms of the disorder. Because Bipolar Disorder is a lifelong and recurrent illness, people with the disorder need long-term treatment to maintain control of bipolar symptoms. An effective maintenance treatment plan includes medication and psychotherapy for preventing relapse and reducing symptom severity, and may at times also include electroconvulsive therapy (ECT).

       Medication: Bipolar Disorder can be diagnosed and treated with medications by Physicians, usually Psychiatrists, and by Physician's Assistants, Psychiatric Nurse Practitioners, and Advanced Practice Registered Nurses. In some states, but not Michigan, Medical Psychologists can also diagnose Bipolar Disorder and prescribe medications to treat it. Check with your state's health professions licensing division to find out more.

       Not everyone responds to medications in the same way. Several different medications may need to be tried before the best combination is found. By keeping a chart of daily mood symptoms, treatments, sleep patterns, and life events a patient can help his treating provider track and treat the disorder more effectively. Sometimes this is called a daily life chart. If a person's symptoms change or if side effects become serious, the treating provider may change medications.  

       Below are some of the types of medications generally used to treat Bipolar Disorder. Information on medications can change, so for the most up-to-date information on medication use and side-effects contact the US Food and Drug Administration at http://www.fda.gov.

       1. Mood stabilizing medications are usually the first choice to treat Bipolar Disorder. In general, people with Bipolar Disorder continue treatment with mood stabilizers for years. Except for Lithium, many of these medications are anticonvulsants. Generally used to treat seizures, anti-convulsants also help to control moods and consequently are commonly used as mood stabilizers in Bipolar Disorder.

  • Lithium (Eskalith; Lithobid) was the first mood-stabilizing medication approved by the US FDA in the 1970s for treatment of mania. It is often very effective in controlling symptoms of mania and preventing the recurrence of Manic and Depressive Episodes. In some cases, Lithium can cause side effects such as:
          — restlessness;
          — dry mouth;
          — bloating or indigestion;
          — acne;
          — unusual discomfort to cold temperatures;
          — joint or muscle pain; and
          — brittle nails or hair.
 
       Lithium can also cause other side effects. If extremely bothersome or unusual side effect occur, tell your treating provider as soon as possible. 
  • Valproic acid or divalproex sodium (Depakote), approved by the US FDA in 1995 for the treatment of mania, is a popular alternative to Lithium for Bipolar Disorder. It is generally as effective as Lithium.
  • Lamotragine (Lamictal), another anti-convulsant, recently received US FDA approval for maintenance treatment of Bipolar Disorder.
  • Gabapentin (Neurontin), topiramate (Topamax), and oxcarbazepine (Trileptal) are sometimes prescribed for Bipolar Disorder. No large studies have shown that these medications are any more effective than other mood stabilizers. Common side effects of these mood stabilizers include:
          — drowsiness;
          — dizziness;
          — headache;
          — diarrhea;
          — constipation;
          — heartburn;
          — mood swings; and
          — stuffed or runny nose or other cold-like symptoms.
 
       2. Atypical antipsychotic medications are sometimes used to treat symptoms of Bipolar Disorder. These medications often are taken with other medications. Atypical antipsychotic medications are called "atypical" to set them apart from earlier antipsychotic medications, which are called "conventional" or "first-generation" antipsychotics.
  • Olanzapine (Zyprexa), when given with an antidepressant medication, may help relieve symptoms of severe mania or psychosis. Olanzapine is also available in an injectable form, which quickly treats agitation associated with a Manic or Mixed Episode. Olanzapine can be used for maintenance treatment of Bipolar Disorder as well, even when the person doesn't have psychotic symptoms. However, some studies show that people taking Olanzapine may gain weight and have other side effects that can increase their risk for diabetes and heart disease. These side effects are more likely in people taking Olanzapine when compared to people prescribed other atypical antipsychotics.
  • Aripiprazole (Abilify), like Olanzapine, is approved for treatment of a Manic or Mixed Episode. Aripiprazole is also used for maintenance treatment after a severe or sudden episode. As with Olanzapine, Aripiprazole also can be injected for urgent treatment of symptoms of Manic or Mixed Episodes of Bipolar Disorder.
  • Quetiapine (Seroquel) relieves the symptoms of severe and sudden Manic Episodes. In that way, Quetiapine is like almost all antipsychotics. In 2006, it became the first atypical antipsychotic to also receive US FDA approval for the treatment of the Depressive Episodes of Bipolar Disorder.
  • Risperidone (Risperdal) and Ziprasidone (Geodon) are other atypical antipsychotics that may also be prescribed for controlling Manic or Mixed Episodes. 
       Common side effects of atypical antipsychotics include:
 
          — drowsiness;
          — dizziness when changing positions;
          — rapid heartbeat;
          — sensitivity to the sun;
          — skin rashes; and
          — menstrual problems in women.
 
       Atypical antipsychotics can also cause major weight gain and changes in a person's metabolism.  This may increase a person's risk of getting diabetes and high cholesterol. A person's weight, glucose levels, and lipid levels should be monitored regularly by the treating provider while taking these medications.
 
       3. Antidepressant medications are sometimes used to treat symptoms of depression in Bipolar Disorder. People with Bipolar Disorder who take antidepressants often take a mood stabilizer, too. This is usually necessary because taking only an antidepressant can increase the patient's risk of switching from depression to mania or hypomania, or of developing Rapid-Cycling Bipolar Disorder. Recently, a large-scale study funded by the NIMH showed that for many people adding an antidepressant to a mood stabilizer is no more effective in treating the depression than is using a mood stabilizer alone.
  • Fluoxetine (Prozac), Paroxetine (Paxil), Sertraline (Zoloft), and Bupropion (Wellbutrin) are examples of antidepressants that may be prescribed to treat symptoms of bipolar depression.

       The antidepressants most commonly prescribed for treating symptoms of Bipolar Disorder can cause mild side effects that usually don't last long. These can include:

          — headache, which usually goes away within a few days;

          — nausea, which usually goes away within a few days;

          — sleep problems;

          — agitation; and

          —- sexual problems for both men and women.

       Some antidepressants are more likely to cause certain side effects than others. Your treating provider can answer questions about these medications. Any unusual reactions or side effects should be reported to your treating provider immediately.

       Psychotherapy: Psychotherapy, or "talk" therapy, can also be an effective treatment for Bipolar Disorder. It can provide support, education, and guidance to people with Bipolar Disorder and their families. Some types of psychotherapy are short-term (10 to 20 weeks) and others are long-term (more than 20 weeks). Which might be suitable for you can be determined between you and the mental health professional whom you see. Some psychotherapies used to treat Bipolar Disorder include:

       1. Cognitive-Behavioral Therapy (CBT). This helps people with Bipolar Disorder learn to change harmful or negative thought patterns and behaviors. CBT helps people change negative and self-critical styles of thinking and behaving that contribute to or worsen symptoms, replacing them with more positive, functional, and adaptive ways. For example, CBT can help people with Bipolar Disorder learn that their manic and depressive episodes are not really random and therefore can be predicted and treated effectively. There are several parts to CBT. These include:

  • Exposure Therapy. This helps people face and control their fears by exposing them to the situation or experience they fear, but in a safe way.
  • Cognitive Restructuring. This helps people neutralize the negative self-talk and irrational belief systems that often underlie Bipolar Disorder.
  • Stress Inoculation Training. This reduces symptoms by teaching the person how to reduce symptoms by looking at his behavior in a more adaptive and functional way.
       CBT often lasts about 12 weeks. It can be conducted individually or in a group of people with similar problems. Group therapy can be particularly effective in treating Bipolar Disorder. CBT often entails “homework,” or exercises, for the client to do in between sessions. Research indicates that the effects of CBT last longer than those of treatment with medication alone for people with Bipolar Disorder. If CBT is effective, a recurrence of the disorder can often be effectively treated quickly and easily with a brief refresher.

       2. Family-Focused Therapy. This includes family members in therapy sessions. It helps enhance family coping strategies, such as recognizing new episodes early and helping to support the person with Bipolar Disorder. This therapy also improves communication and problem-solving skills.

       3. Interpersonal and Social Rhythm Therapy. This helps people with Bipolar Disorder improve their relationships with others and manage their daily routines. Regular daily routines and sleep schedules may help protect against Manic Episodes.

       4. Psychoeducation. This teaches people with Bipolar Disorder about the disorder and its treatment. It helps people recognize signs of relapse so that they can seek treatment as early as possible, before a new episode becomes more difficult to manage. Usually done in a group, psychoeducation may also be helpful for family members and caregivers. 

       A Licensed Psychologist, Social Worker, or Counselor typically provides psychotherapy. The mental health provider often works with the Psychiatrist to track progress. The number, frequency, and type of sessions should be based on the treatment needs of the patient. As with medication, following the mental health provider's recommendations in psychotherapy will provide the greatest benefit.

       Electroconvulsive Therapy (ECT): For cases in which medication and/or psychotherapy doesn't provide adequate relief of symptoms, ECT may be useful. ECT, formerly known as "shock therapy," once had a bad reputation. In recent years it has greatly improved and can provide relief for people with severe Bipolar Disorder who haven't improved with other treatments.

       Before ECT is administered, the patient takes a muscle relaxant and is put under brief anesthesia. He doesn't consciously feel the electrical impulse administered in ECT. On average, ECT treatments last from 30 to 90 seconds. People who undergo ECT usually recover after five to 15 minutes and are able to go home the same day.

       Sometimes ECT is used for bipolar symptoms when other medical conditions, including pregnancy, make the use of medications too risky. ECT is a highly effective treatment for severely Depressed, Manic or Mixed Episodes, but is generally not a first-line treatment.

How can you help someone who has Bipolar Disorder?

       If you know someone who has Bipolar Disorder, odds are that it affects you, too. The first and most important thing that you can do to help a friend, family member, or coworker who has Bipolar Disorder is to help him get diagnosed and treated. You might have to schedule an appointment on behalf of the person or even go with him to see a provider. Encourage him to stay in treatment or to seek different treatment if no improvement occurs after six to eight weeks of medication or eight to 12 weeks of psychotherapy. To help more, you can:

  • offer emotional support, understanding, patience, and encouragement;
  • learn about Bipolar Disorder so that you can understand what the person is experiencing;
  • talk to the person and listen carefully;
  • listen to feelings the person expresses -- be understanding about situations that might trigger bipolar symptoms;
  • invite the person out for positive distractions, such as walks, outings, and other activities; and
  • remind the person that, with time and treatment, he can get better.

    © 2010
    Dr. Thomas E. Hranilovich
    Licensed Psychologist

Psychiatric Associates / 4084 Okemos Rd. / Suite A / Okemos, MI 48864
Phone: (517) 347-4848 / Fax: (517) 347-4844