Dr. Gus Alva shares his initial impressions on this case and treatment approaches to bipolar 1 disorder.
Gus Alva, MD, DFAPA: I think that this particular clinical history encapsulates some very fascinating points. Among these points might be what our first impression of this case might be, and what types of challenges a patient like this presents when they come into treatment. This is a young female patient of child-bearing age, who, upon speaking about her current symptomatology, one would immediately latch onto the concept that depressive symptoms are in play, as she has had several episodes that look like this. Upon further investigation, it turns out that there might be some mood oscillation in the background, which is a very important point, particularly in the primary care setting but also in the specialist setting. Our patients are not going to be the best historians; that means that sometimes we miss subtle points of import, such as periods of either mood oscillation, excessive activity, decreased need for sleep, irritability, and impulsivity. In the case of our patient, we certainly note that aside from depressive episodes she has had, she has certainly had some mood oscillatory issues that we need to keep in mind.
Some of the red flags to keep in mind include different factors, such as lingering vegetative symptoms. She has been fine with treatment that might actually work for most individuals. She has been exposed to an SSRI agent that has been ramped up sufficiently. We note, however, that as dose was being ramped up, a bit of activation occurred. Sometimes, the thought in mind should be: Are we potentially evoking medication that doesn’t work for our patient as opposed to actually reconsidering the possibility that in our differential of major depressive order that bipolar disorder may not have been captured previously. We know that family history is strongly burdened by the possibility of mood oscillatory states, and this would be indicative of problem. We know that her age and medical comorbidities are of great import. We obviously want to make sure that someone who is already weighing a little extra is not exposed to agents that might pack on more weight, and, as a consequence of that compromise, the possibility of continued use of medications that otherwise would be highly advantageous. We know that when someone walks into clinical setting and say they have been depressed the past 2 weeks, are experiencing vegetative symptoms that are impacting their day-to-day life and interactions with others, we don’t always jump to the conclusion of unipolar depression. DSM-5 stipulates that differential diagnosis of bipolar disorder of depressive episode be kept in mind. Our case her illustrates those very points.
You’ll note that initially she was managed with psychotherapy but then, subsequently, the thought was, are we barking up the wrong tree? Should we seek out some specialty care that was done in appropriate manner. In the past, we would have thought that different types of mood stabilizing medications, which typically would be a but more useful in individual who are experiencing a bit more manic or mixed symptomatology. Sometimes we don’t capture the essence of countering specific problems with an agent that might actually have a profile that is attractive for an individual like our patient.
In the primary care setting, when someone sees a PHQ9 of 18 that designates severe depression. But we now see couched behind that the mood disorder questionnaire as a way of propelling additional dialogue about the possibility of bipolar disorder based on current depressive symptoms the patient is experiences. Obviously, an SSRI would not be the indicated agent to utilize in this patient at this particular juncture, because she has been experiencing more depressive symptoms that are tied in with bipolar disorder. In this case, a mood stabilizer that could have a nice impact on lifting depressive symptoms would probably be of greater benefit, keeping in mind the weight related issues and the fact that she is already diabetic and we don’t want to aggravative underlying metabolic issues. There are also other agents that might actually help out in stabilizing mood, particularly when someone is experiencing a depressive episode. We know that within the family of the antipsychotics would be agents that would address symptomatology that this patient is experiencing. But we want to keep in mind the overall ambulatory state of the individual. if someone is having problems with sleep, they will seek out an agent that helps with sleep but then subsequently might complain that they feel “out of it”; that is where agents that have a profile that is not necessarily evoking too much sedation might be useful. Sometimes, taking a medication with or without food could create an impediment for someone to actually comply with their utilization with the medicine and the dosing associated with the medicine would be of great import. Taking into context the overall profile of these medications based on the data available is also of great aid.
This case illustrated that if it walks, quacks, moves around like a duck, it might well be a chicken. In this case, it is well worth while reconsidering what our diagnosis is and consider the possibility of a mood disorder like bipolar disorder. We noted that at the very least she had had flares with her mood, where she did not need to sleep as much and felt more active and productive. Peering into those periods would be a great benefit for us in solidifying a diagnosis. Ultimately, when we try to get someone on the right trajectory. It is about getting the right questions in front of the person, to be able to unmask underlying issues that may have been in play. Although the lifetime problems for major depressive disorder are far greater than for bipolar disorder with depressive episodes, those of us who manage specialty settings often see individuals who bounce back between different clinicians and are now surprised that some people take 5 to 10 years before right diagnosis is made. This case readily illustrates multiple points that we need to keep in mind and helps solidify the approach that should be held with patients. There is no preset way of diagnosing individuals; our diagnosis can sometimes be fluid. That is why it is so important to look at family history and previous symptomatology, and maybe the possibility of individuals who have been misdiagnosed, having had psychiatric comorbidities that would be indicative of the likelihood of a condition like bipolar disorder.
Transcript Edited for Clarity