Michael E. Thase, MD

Videos

Michael E. Thase, MD; Theresa Cerulli, MD; Gustavo Alva, MD, DFAPA; and Tina Matthews-Hayes, DNP, FNP, PMHNP, provide insight on the role of telemedicine in improving outcomes for patients with bipolar disorder.

Role of Telemedicine in Bipolar Disorder

A panel of experts in psychiatry consider the use of a novel second-generation antipsychotic for the management of treatment resistant depression.

Patient Case #2 Continued: Novel Second-Generation Antipsychotics

Michael E. Thase, MD, presents the case of a 47-year-old man with treatment resistant bipolar depression.

Patient Case #2: 47-Year-Old Man With Treatment Resistant Depression (TRD)

Psychiatric experts consider mood stabilizers when treating bipolar disorder and review the role of antidepressants in disease management.

Treatment Options for Bipolar Disorder

:I’m going to ask first Theresa and then Tina, do you think this case presented particular diagnostic difficulties for her primary care physician? And what might you have done differently to speed the accurate diagnosis and a perhaps more useful treatment plan? What do you think, Theresa?

: It is very challenging, particularly in a primary care setting, where there’s not as much time to be able to ascertain the longitudinal perspective from the patients. Primary care physicians are on the front line trying to make sure they’re not missing any glaring medical problems, with the complication of what’s psychiatric and what’s medical; it is very difficult to do in a short session. Tina mentioned using some screening tools. What might I have done differently? Screening tools can help, but not diagnose, I really want to emphasize that.

This was just yesterday, in my own practice, I got a call from a patient who said, “My therapist administered the MDQ [Mood Disorder Questionnaire], and I have bipolar disorder.” I had to back up and explain that it is very helpful to use screening tools such as the MDQ, the Mood Disorder Questionnaire, to help us then better discern what is and is not bipolar. But it’s a screening tool, not a standalone diagnostic tool. We’re the diagnostic tool, the clinician, doing a very thorough evaluation.

So, in a primary care setting, maybe there is time just for the screener, which is absolutely helpful to taking next steps and getting the patients what they need. I want to add the reason this is so important, why we are talking about this, is outcomes. Not only is it taking us 5 to 10 years to accurately make the diagnosis of bipolar disorder, but the outcomes in that time, if there’s a neuroprogressive problem here, the more episodes of depression, or mania, or mixed episode that patient has, the more they are going to have.

The outcomes are worse in terms of the comorbidities, the risk of suicide is anywhere from 4% to 19%. That’s combining the data on bipolar I and bipolar II, but 4% to 19% of these folks will have completed suicide. It’s not just attempts. Attempts are more in the 25% to 60% range; 25% to 60% of patients at one point during their lifetime will attempt suicide with a diagnosis of bipolar I and bipolar II combined. This is a very serious condition for us to be more quickly and accurately assessing and treating.

:Tina, yes or no, would you have made the diagnosis quicker as you use the Rapid Mood Screener?

: I believe I would have. Again, I’m spring boarding off a lot of things that have been said here. Just reiterating what Dr Cerulli said, the tools are very helpful, but essentially we’re like detectives, going back and looking at the history again and the epigenetics. What is the family history here? Looking at their first depressive episode. The key to this patient case is, she was young and had multiple failures of SSRIs [selective serotonin reuptake inhibitors]. We know there are about 3 dozen antidepressants approved for depression. Why would I pick a fourth, or fifth, or sixth, why would I not try a second-generation medication and try to target dopamine?

One of the things that Dr Alva mentioned and I’d like to segue to is when people get stuck with, “I don’t want to be bipolar,” I always tell them, this is no different than being a diabetic. It’s just a dopamine dysregulation, so where we would have an insulin or an islet cell issue, we’re just having a mesolimbic issue, therefore making it more of a physiologic issue versus a failure that they perceive with the word bipolar. It is a dopamine dysregulation, and we have to target it. We’re chasing the wrong horse with serotonin, norepinephrine, or whatever. “Let’s try to target a different horse of dopamine and see if we can even this out for you.”

Dr. Thase is a professor of psychiatry at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, Pennsylvania.

Dr. Alva is the medical director of ATP Clinical Research in Costa Mesa, California.

Dr. Cerulli is the medical director of Cerulli and Associates in Andover, Massachusetts.

Dr. Tina Matthew-Hayes is a dual certified nurse practitioner at Western PA Behavioral Health Resources in West Mifflin, Pennsylvania.

Theresa Cerulli, MD, and Tina Matthew-Hayes, DNP, FNP, PMHNP, review diagnostic difficulties of the patient’s primary care physician in patient case #1 and share optimal approaches to the diagnosis and treatment for patients with bipolar disorder.

Diagnosis of Bipolar Disorder

:As you know, the MDQ [Mood Disorder Questionnaire] has a relatively short life. I think it is less than 25 years old, but at the same time, there are problems with false positives, particularly for patients in the cluster B [personality disorders] area. For someone with ADHD [attention-deficit/hyperactivity disorder], can you think of more recent developments that might complement the MDQ as a screener? What are you doing in your practice these days?

: Again, the MDQ is a strong tool. We should definitely be using it. It can definitely be complemented with the use of the new RMS [Rapid Mood Screener] tool as well. I think one of the biggest pieces in this is when you’re working with a patient, there’s a lot of practice where we hand them a test and say, “Take this test, give it back to us, and we’re going to screen you on the test.” I think human beings by nature want to answer the questions correctly, and a lot of patients don’t want to be told that they have bipolar disorder. I think if we can work the questions, especially the RMS questions, or part of the MDQ if time prohibits, into our evaluation, we can get more authentic and honest answers from our patients. Because it’s a snap, “No.” Or they maybe pause and they’re like, “Hmm, no.” Well, “You paused, what does that mean? Tell me what that means.” I think sometimes in communicating with our patients, we get much more authentic answers that can lead us to a correct diagnosis.

:Thank you. Why don’t we go ahead and go from the general to the specific now and talk about our particular patient and the case history. Gus, what was your overall impression of this young woman? Do you think you could help her?

: Absolutely. We can always help people out. It will be important to address that 1 out of 4 individuals who get diagnosed with major depressive disorder when they are seen in the general setting actually have bipolar disorder. Oftentimes, when they’re being sent over to us within the specialty setting, I think it is useful to be able to address some different things that we are seeing before us. In this individual patient’s case, obviously being able to interpret what the Mood Disorder Questionnaire results look like would be a nice stepping stone. Along the lines of saying, “Hey, this is not a definitive tool,” but it opens the door for us being able to speak about additional factors that might help us think about bipolar disorder and what the patient is experiencing, not just depressive symptoms but certainly mixed symptoms. This is somebody who would have atypical features of depression. She’s hypersomnolent, but she’s also hypersexual. Taking a look at additional elements like family history, or the fact that she was struck by this particular problem early on, might be very helpful.

Because individuals are being diagnosed earlier rather than later and have comorbidities, such as bipolar disorder or anxiety-related symptomatology, having the mood-related episodes and medication misadventures, these additional factors help create a specific story of what exactly this diagnosis is. Bipolar is not a label that one should adopt, it’s simply a medical condition that needs to be recognized and dealt with appropriately. As mentioned, people oftentimes don’t want to be bipolar, so we will say, “We're not ascribing this label to identify you, we’re identifying a medical condition that you probably have carried for a while, and now we’re going to deal with it appropriately.”

Tina Matthews-Hayes, DNP, FNP, PMHNP, comments on screening tools for bipolar disorder and Gustavo Alva, MD, DFAPA, shares his impressions from patient case #1.