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Clinical Challenges in Bipolar Disorder

Clinical Challenges in Bipolar Disorder

Terence A. Ketter, MD


Dr Ketter is Professor Emeritus of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA.

Editor’s Note: We are pleased to present this Q&A with Dr Ketter, based on his presentation at the 2017 Psychiatric Congress, “Solving Clinical Challenges in Bipolar Disorder.” Dr Ketter’s presentation takes place on Sunday, September 17 at 9:15 am.

The presentation “Bipolar Disorder—Solving Clinical Challenges,” strives to address complex conundrums commonly faced by psychiatrists when managing their patients with bipolar disorder. Highlights are summarized here.

Q: What are some of the issues that psychiatrists who treat patients with bipolar disorder face?

A: Crucial diagnostic challenges include distinguishing bipolar disorder from unipolar major depressive disorder. Crucial therapeutic challenges include prioritizing efficacy (therapeutic effects) versus tolerability (adverse effects) and managing adverse effects (especially weight gain/sedation versus akathisia). Although adjunctive (added to pharmacotherapy) psychotherapies have proven useful, there remains limited access to evidence-based treatments.1

Q: What do you mean by diagnostic nosology?

A: Diagnostic nosology is our system of diagnosing psychiatric disorders, which currently in the US is based upon DSM-5, which was published in 2013. Even with the advances in DSM-5 nosology, accurate diagnosis of bipolar disorder remains challenging because of its: (1) complex, variable symptoms (with different bipolar subtypes, mood states, courses, and age-dependent presentations); and (2) confounding comorbidities (eg, substance abuse, anxiety, disruptive behavioral [ADHD, oppositional defiant, and conduct], and Cluster B disorders).

DSM-5 has some clear limitations, including failing to integrate well-established bipolar outcome risk factors for depressive presentations such as: depression onset prior to age 25 years; depression with lifetime history of psychosis; and depression with at least one first-degree relative with mania.2

Q: Are the criteria new for assessing and diagnosing bipolar disorders?

A: Yes. DSM-5 has added the mixed features specifier for manic, hypomanic, and depressive episodes. DSM-5 has also permitted full hypo/manic episodes emerging during antidepressant treatment and persisting beyond the expected duration of physiological antidepressant treatment effect to be sufficient for hypo/manic episodes (ie, considered bipolar disorder rather than mere antidepressant-induced hypo/manic episodes).

Q: Are there any new screening tools for bipolar disorders?

A: Screening tools have yet to integrate DSM-5 advances, and are thus still based on DSM-IV (ie, the Mood Disorder Questionnaire for Hypo/Manic episodes (4), and the Patient Health Questionnaire for Depressive episodes3,4).

Nevertheless, the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) study Clinical Monitoring Form (CMF) to establish clinical status at each visit proved very useful.5 CMF assessments entailed diagnosing 4 DSM-IV syndromal episodes (depressed, hypomanic, manic, mixed), 2 subsyndromal states (continued symptoms, roughening), and 2 euthymic states (recovered, and recovering). Clinical statuses indicated if new mood interventions were: (1) practically mandated (for syndromal episodes); (2) elective (for subsyndromal states); or (3) commonly avoided, unless there are adverse effects (for euthymic states).

Q: What are the latest treatment guidelines for bipolar disorders?

A: Treatment guidelines have integrated efficacy/tolerability in assessing treatment options. The British Association for Psychopharmacology published bipolar disorder treatment guidelines in 2016 (which were not based on DSM-5).6 Unfortunately the last complete American Psychiatric Association Bipolar Disorder Guideline was a decade and a half ago (in 2002), with only a partial update in 2005-2007.7,8


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