Dialogs in Bipolar Depression: Q&A

What are the most challenging aspects of correctly diagnosing patients who present with multiple medical and psychiatric symptoms?

CARTER: It is always a challenge when faced with a patient who may be depressed, irritable, scattered, focused on the treatment he/she wants, revealing little about their past, and refusing to have collateral input from family and friends. We must maintain a high index of suspicion for bipolar disorder, stay patient focused yet not allow the patient to dictate the treatment he/she wants until we are more confident that we have an accurate picture of the patient’s problems. Quite a challenge!

KABINOFF: Bipolar diagnosis can be complicated, especially when combined with multiple medical comorbidities. The first obligation for a physician is to rule out any organic pathology or substance abuse that may be causing or mimicking bipolar symptomology. A thorough psychiatric history over a longitudinal life course invaluable and should be undertaken in every patient with depression.

KNOBLICH: When asking this question to PCPs around the country, I consistently hear that time is the most challenging obstacle in treating psychiatric disorders in the context of multiple medical problems. The use of patient selfrating mood symptom questionnaires is a great time saver that not only documents symptom severity at baseline, but also enables providers to gain the most information in the shortest amount of time. These validated questionnaires can not only screen for mood disorders, but can be used at every follow-up visit, aiding in more comprehensive evaluation and management. Furthermore, these self-rating symptom surveys have proven immensely valuable in my practice. They educate patients about the signs and symptoms of their illness and chart their improvement over time, which has proven to be an important component in improving longterm treatment adherence.

Which screeners, scales, or other rating instruments do you use in your practice when evaluating patients? Are some more useful in certain circumstances?

CARTER: I use the MDQ if a patient presents with a complex picture with treatment failures. However, it is very difficult for a patient with a depressed sensorium, racing thoughts, or irritability to present a clear psychiatric history of prior problems. I must ask specific questions about legal problems, times with poor judgment, periods of decreased sleep, suicide attempts, DUIs, substance abuse, etc. They rarely volunteer such information.

KABINOFF: Most primary care physicians are astute at questioning for depressive symptoms, In contrast, we are poor at evaluating for the manic side of symptomology. The mood disorder questionnaire or MDQ is a very helpful screening tool for these patients.

KNOBLICH: For more than 10 years I have used a simple list of depression and anxiety symptoms that asks patients to rank on a scale of 0-3 the frequency (not severity) of their symptoms over the prior 1-2 weeks. The PHQ-9 is a rating scale for depression that can be used as a depression screen or at follow-up visits. Patients complete this at every visit in the exam or waiting room prior to being seen. In a few seconds, I have a good idea about the patient’s current symptoms. I have found the MDQ to be an essential instrument to screen for bipolar disorder in every patient who has any depressive, anxious, or attention deficit symptoms and in all patients with any substance abuse. I also utilize an ADHD screener, such as the ASRS.

How important is treatment adherence to long-term success in patients with bipolar depression? What are some of the most common barriers to adherence and how can physicians promote better treatment adherence among patients?

CARTER: Patients do not want to be diagnosed with bipolar disorder; therefore, part of their treatment involves psychoeducation and helping them experience a better life with treatment. Once patients feel better and function better, they are more willing to stay in treatment. If the medication does not adequately treat the symptoms, the patients will stop taking it. We must treat to remission of symptoms. We must discuss lifestyle issues: exercise and fitness, nutrition, maintenance of healthy weight. An active, healthy lifestyle will help our patients become more stable.

KABINOFF: Physician—patient relationships are paramount to successful therapy. When physicians understand the nature of the illness, as well as having an understanding of medi-cat-ions, side effect profiles, and management around these issues, patients stand a better chance of successful therapy.

KNOBLICH: Bipolar depression is a highly recurrent and/ or a persistently severe disorder of mood and psychosocial functioning. Most patients will recur many times in their lives, and long-term studies reveal that patients with bipolar disorder spend upward of 50% of their adult lives depressed. As such, a comprehensive treatment regime that includes necessary lifestyle modifications, sleep and stress regulation, and proven pharmacotherapy to attain and maintain remission is paramount to optimal outcomes. Disease state education and debunking the stigma of bipolar disorder is essential in bringing the patient into agreement regarding the need for treatment.

How do you address a patient’s substance abuse problem when treating for bipolar depression?CARTER: As I mentioned earlier, substance abuse is common in the bipolar patient. Even if a patient is still actively using drugs or drinking alcohol to excess, it is important to start treatment to help stabilize the mood and reinforce the need to quit. As the patient improves in mood and cognition, he/she may be more receptive to a discussion of their substance abuse. Working in a mental health center setting, where many of my patients have co-morbid substance abuse, I have made it very clear to the patients that they will not be receiving addictive medications from me, specifically benzodiazepines, stimulants, and narcotics.

Many drug court and mental health court patients carry bipolar diagnoses, and it is very helpful that they are drug tested and penalized if found to be using. Drug abuse, especially methamphetamine, is extremely difficult to quit, so having legal help in enforcing appropriate behavior and treatment compliance has proved to be extremely beneficial for the patients’ recovery, which is slow but possible.

KABINOFF: Comorbid substance abuse is present in a high percentage. I have found as patients have efficacious treatment with mood stabilizing agents, much of this behavior is curtailed, since in many situations, the substance abuse is a way of self medication to help with their symptomology.

KNOBLICH: I find that many patients with bipolar depression have a long history of self medicating their mood symptoms. Studies indicate that up to two-thirds of patients with bipolar depression have a co-morbid substance abuse disorder. The depression will not remit if substance abuse is active, so it is helpful to ascertain what the patient is attempting to “treat” with self medication, and, if possible, target those symptoms with initial pharmacotherapy. I discuss with the patient the contributing role their substance use plays in their depression and urge them to enter into an acceptable substance abuse treatment program.

How do you define successful treatment?CARTER: Successful treatment for bipolar patients must involve some insight into their illness, and hopefully when stresses occur, they will get help. Insight means knowing that you need to stay on medication and value how you feel when taking it. One of the hallmarks of the illness is denial of illness. Treatment must focus on a medication that is effective, helping the patient gain insight into the illness.

Successful treatment of bipolar patients does not presently equate with “cure.” They must remain on medication, and they will not do so unless they have insight into the nature of their disorder. This means they must know that they need to stay on medication, and they must appreciate how they feel when taking it. An effective medication must be selected (and today effective medications are available), and the patient must be brought to understand their illness. I believe that treatment is successful when the patient achieves a functional lifestyle relative to the severity of their illness and is able to, and does, maintain their medication regimen.

KABINOFF: Successful treatment for me is restoring a patient’s life in multiple domains. To restore their functioning in society, work, and interpersonally, as well as minimizing symptoms and relapse, is our goal.

KNOBLICH: Optimally defined, successful treatment is the combination of sustained symptom resolution and a full return to pre-morbid psychosocial functioning. But as I have gained more years of experience with treating bipolar depression, I realize that “successful treatment” will mean different things to different patients. Bipolar depression is a chronic, relapsing, and highly pleomorphic mood disorder. I’ve learned that many patients will experience life-changing treatment responses, while others will continue to experience residual symptoms and recurrent mood episodes. For these patients, successful treatment is often defined as remaining in treatment, with an intact social support system and with the perseverance of hope that with time and further treatment advances they will once again attain a full and contented life.