Around the Practice: Identification and Management of Bipolar Disorder - Episode 2
A panel of experts in psychiatry share insights on the challenges and importance of making an accurate diagnosis of bipolar disorder.
Michael E. Thase, MD: Let’s move on to our next polling question. The patient in case 1 is currently not taking any mood stabilizing medication. Which of the following treatment options would you have most likely started with this patient? a. lithium, b. quetiapine, c. divalproex, d. lurasidone, or e. cariprazine.
Why don’t we go ahead and talk some about our patient. Gus, join me, if you will.
Gustavo Alva, MD, DFAPA: I’d be happy to.
Michael E. Thase, MD: What do you think the clinical significance is of making the diagnosis of bipolar disorder in this patient?
Gustavo Alva, MD, DFAPA: It’s quite significant. Obviously, this is a terrific example of the fact that sometimes people go about life without necessarily receiving an appropriate diagnosis for a while. We know that based on the literature, sometimes people go 5 to 10 years before ascertaining the appropriate diagnosis. Part of the problem with that is that oftentimes people are challenged by additional problems because of the fluctuation with their mood and their inability to reach the goals that they’re after, whether it be socially, occupationally, interpersonally.
This case is really interesting, but obviously, we would want to find out a bit more information about what’s been happening with her. The fact that she’s been, again, having difficulties or problems brought about by the antidepressant choices that she’s received previously become sort of a common theme that we oftentimes see in the clinical setting.
Oftentimes, when people experience mood oscillation or fluctuation and the mixed symptomatology that she’s having right now, these are sort of characteristic of the complexity of symptomatology that patients will present with.
Now, we obviously know that there’s a 17% lifetime prevalence rate for major depressive disorder, and that bipolar disorder pales in comparison based on percentages. Literature would suggest this is, at the most generous, up to 4% if you were to lump in bipolar I and II together. However, when we consider somebody with a major depressive episode, a differential diagnosis of bipolar disorder and a depressive episode is certainly one that we should be considering.
I think that this particular case is quite interesting in that it brings so many different elements to the forefront that help us, along the lines of medication misadventures and the possibility of barking up the wrong tree and not necessarily addressing the underlying issues that we need to be getting to.
Michael E. Thase, MD: Thanks, Gus. Theresa, this young woman has an antecedent history of ADHD [attention-deficit/hyperactivity disorder].Do you find that surprising?
Theresa Cerulli, MD: Not at all, Dr Thase, not at all. I’m a neuropsychiatrist in clinical practice in the Boston area, and this case is so illustrative of most of the patients I’m getting referrals on.
I have had an area of interest within ADHD for years, and many of my patients with bipolar disorder are those who were previously diagnosed in childhood with ADHD. This is more common than not. The comorbidities with bipolar disorder are so elevated, it is one of the reasons it is so difficult to make this diagnosis accurately. As Gus already explained, we are now looking at a 5- to 10-year delay in making the diagnosis of bipolar disorder accurately. There is so much need for patient education and clinician education alike to help raise awareness of what this really looks like in clinical practice.
The comorbidities that are most common, certainly the differential between bipolar disorder and major depressive disorder, is a tough one. Most patients are coming in depressed, as our hypothetical patient in this case. They often do have features, in this case some of the reasons it’s hard to differentiate and diagnose our young woman, our 27-year-old, is the history of her ADHD, and the fact that she has had recurrent depressive episodes with some mixed features that could be mixed up with things like the reactivity, the higher energy, the irritability of ADHD.
It is easy to miss that this was actually a bipolar picture if not yet having seen the full manic symptoms. We’re really looking at risk factors to be able to help identify who the patients are who are truly, in the history, the longitudinal perspective, at risk for bipolar as opposed to unipolar depression or just an ADHD anxious, irritable picture, which is so commonly where these folks get lumped into.
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.