Around the Practice: Identification and Management of Bipolar Disorder - Episode 3

Clinical Impressions From Patient Case #1

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Custom Around the Practice Video Series

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.

Michael E. Thase, MD: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?

Tina Matthews-Hayes, DNP, FNP, PMHNP: 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.

Michael E. Thase, MD: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?

Gustavo Alva, MD, DFAPA: 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.”

Transcript Edited for Clarity

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.