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.
Michael E. Thase, MD: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?
Theresa Cerulli, MD: 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.
Michael E. Thase, MD:Tina, yes or no, would you have made the diagnosis quicker as you use the Rapid Mood Screener?
Tina Matthews-Hayes, DNP, FNP, PMHNP: 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.”
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.