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CME / ABIM MOC / CE

Module 1: Clinical Queries in Bipolar Depression: What Tools Are Best for Screening and Diagnosis?

  • Authors: Denise Vanacore, PhD, FNP-BC, PMHNP-BC; Manpreet Kaur Singh, MD, MS
  • CME / ABIM MOC / CE Released: 9/27/2022
  • Valid for credit through: 9/27/2023
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  • Credits Available

    Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™

    ABIM Diplomates - maximum of 0.25 ABIM MOC points

    Nurses - 0.25 ANCC Contact Hour(s) (0 contact hours are in the area of pharmacology)

    Pharmacists - 0.25 Knowledge-based ACPE (0.025 CEUs)

    IPCE - 0.25 Interprofessional Continuing Education (IPCE) credit

    You Are Eligible For

    • Letter of Completion
    • ABIM MOC points

Target Audience and Goal Statement

This activity is intended for primary care physicians, psychiatrists, nurse practitioners, physician assistants, nurses, and other healthcare providers who care for patients with bipolar disorder.

The goal of this activity is that learners will be better able to recognize bipolar depression in a timely manner through the use of evidence-based tools and a team-based approach.

Upon completion of this activity, participants will:

  • Have greater competence related to
    • Implementing tools to facilitate a diagnosis of bipolar depression
  • Demonstrate greater confidence in their ability to
    • Incorporate interprofessional strategies in bipolar depression screening


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Faculty

  • Denise Vanacore, PhD, FNP-BC, PMHNP-BC

    Associate Dean and Professor of Nursing
    Eastern University
    St. Davids, Pennsylvania

    Disclosures

    Denise Vanacore, PhD, FNP-BC, PMHNP-BC, has no relevant financial relationships.

  • Manpreet Kaur Singh, MD, MS

    Associate Professor of Psychiatry and Behavioral Sciences
    Stanford University
    Stanford, California

    Disclosures

    Manpreet Kaur Singh, MD, MS, has the following relevant financial relationships: 
    Consultant or advisor for: Alkermes; Johnson and Johnson; Neumora; Skyland Trail (On the National Advisory Board); Sunovion 
    Research funding from: Johnson and Johnson  
    Royalties from: Thrive Global

Editor

  • Clinton W. Wright, PharmD, BCPP

    Medical Education Director, Medscape, LLC 

    Disclosures

    Clinton W. Wright, PharmD, BCPP, has no relevant financial relationships. 

Compliance Reviewer/Nurse Planner

  • Stephanie Corder, ND, RN, CHCP

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Stephanie Corder, ND, RN, CHCP, has no relevant financial relationships. 

Peer Reviewer

This activity has been peer reviewed and the reviewer has no relevant financial relationships.


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CME / ABIM MOC / CE

Module 1: Clinical Queries in Bipolar Depression: What Tools Are Best for Screening and Diagnosis?

Authors: Denise Vanacore, PhD, FNP-BC, PMHNP-BC; Manpreet Kaur Singh, MD, MSFaculty and Disclosures

CME / ABIM MOC / CE Released: 9/27/2022

Valid for credit through: 9/27/2023

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Activity Transcript

Denise Vanacore, PhD, FNP-BC, PMHNP-BC: Hello. I'm Dr Denise Vanacore, Associate Dean and Professor of Nursing at Eastern University in Wayne, Pennsylvania. Welcome to this program titled Module One: Clinical Queries in Bipolar Depression: What tools are Best for Screening and diagnosis? Joining me today is Dr Manpreet Singh, Associate Professor of Psychiatry and Behavioral Sciences at Stanford University. Welcome.

Manpreet Kaur Singh, MD, MS: Thank you, Denise. Glad to be here with you today.

Dr Vanacore: We're going to begin by talking about a case, and this case is a 27-year-old teacher who presents with symptoms of depression. She a new treatment naïve patient and has never been seen by psychiatry or primary care. She fills out the Rapid Mood Screener (RMS). What will the RMS tell you about this patient's depressive symptoms?

Dr Singh: The RMS is a new kid on the block. It's a 6-question screener to remind practitioners to ask about mania symptoms and risk factors for mania symptoms when they are evaluating someone who presents with mood symptoms. For example, practitioners will ask if the patient has had at least 6 different periods of time lasting at least 2 weeks when they felt depressed as well as when a patient felt very depressed, if they had problems with depression before the age of 18, if they had to stop or change an antidepressant because it made them highly irritable or hyper. Or if they've ever had a period of at least one week during which they were more talkative, had racing thoughts, were unusually happy, outgoing or energetic, or had any period where they needed less sleep.

These cardinal symptoms that are very common are kind of early warning signs, or potential warning signs that there might be a bipolar diagnosis. If you use a rapid screener, affirmative responses to 4 out of the 6 questions is indicative of a positive screen for bipolar disorder versus MDD. That gives you a clue that you might need to probe a little bit deeper.

Dr Vanacore: Great. We've looked at this patient and she did score a 4, and she's endorsed that she is experiencing a decrease in sleep. How do you determine clinically if this patient has bipolar disorder versus MDD?

Dr Singh: The first thing I'll do is oftentimes confirm a diagnosis of depression, and I'll use diagnostic criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), which tells us that we need to be looking out for a depressed mood or loss of interest or pleasure and anhedonia. Plus the SIGECAP [sleep, interest, guilt, energy, concentration, appetite, psychomotor] symptoms, whether it's sleep, decreased sleep or excessive sleep, psychomotor agitation or retardation, fatigue, loss of energy, guilt, impairments and concentration. And then of course, assessing for suicidal thoughts or behaviors. And of course the depression needs to be present for at least 2 weeks or more to meet criteria for an episode, and must impair functioning and cause significant distress and not be attributable to substance use or other medical conditions.

Dr Vanacore: Right, so how would you take that next step in looking at bipolar depression versus a manic or hypomanic episode?

Dr Singh: Our teacher has had an evaluation, confirmed depression, and we've done an RMS that seems to suggest there might be something more than straight depression going on. I'll go into the DSM-5 diagnostic criteria for bipolar disorder, which we'll talk about in a moment.

But one of the first things we want to do is assess for level of severity is mania. Full threshold, as in a manic episode, requires at least a week or more or might necessitate hospitalization because of the marked impairment and functioning. This may be attributable to psychotic symptoms or other areas of impairment in a patient's life that lands them in the hospital. If you have euphoric or excitable moods, then you only need 3 or more core symptoms. If you're primarily irritable, you'll need 4 or more. In a hypomanic situation, it's generally distinguished by time criteria.

A manic episode requires that symptoms last at least a week and be present for most of the day with that index mood plus associated symptoms. A hypomanic episode usually lasts at least 4 days or more and is generally less severe, not as functionally impairing, usually doesn't lead to hospitalization, and usually the patient hasn't had a history of a prior manic episode.

Dr Vanacore: We now know this patient has MDD, and she does not have a history of mania or hypomania. How would you treat and monitor this patient long term?

Dr Singh: Constant evaluation and reevaluation is necessary. Ruling out bipolar disorder can be very helpful, because it can help us understand where we might go in terms of treatment. I'd be more comfortable, for example, starting a patient on an antidepressant having known that if I'm getting some screening symptoms, I've actually done the due diligence to rule out bipolar disorder. Because giving a patient an antidepressant, for example, could actually lead to activation of mania or hypomania symptoms. To treat unipolar depression, I would follow the usual treatment guidelines for treating unipolar depression, and then I'd still do the business of constantly evaluating and reevaluating.

Denise, patients come into my office and I assess for mania symptoms as well as depressive symptoms at every single encounter. That enables me to ensure that I'm not missing mania symptoms in those patients that are presenting with a mood disorder.

Dr Vanacore: I know one good pneumonic for assessing manic features or manic symptoms during a clinical assessment is DIG FAST [distractibility, impulsivity/indiscretion, grandiosity, flight of ideas/racing thoughts, sleep deficit, talkativeness]. Can you talk a little bit about that pneumonic and how you use that in clinical practice?

Dr Singh: We oftentimes get to the trouble that's associated with a mania symptom pretty quickly because that's what patients present with, their impairment and functioning. But what I would say is that you've got to start first with asking the patient how they're feeling. What is the index mood? Is it euphoria, cheerful, high, terrific, not feeling your normal self? Or is it irritability and maybe of an explosive nature. And then after you've established that index mood and you, for example, established the time criteria, how long has it lasted? Every day, 50% of the day for at least a week? 4 days or less? That gives us some idea of whether we're dealing with subsyndromal or syndromal mania. And then you go into the associated symptoms. What hangs with that euphoric, elevated, cheerful mood or explosive irritability? Because if it's euphoric, then you'll need at least 3 symptoms. And if it's explosive irritability, then you'll need more symptoms, or 4 symptoms of DIG FAST.

So what is DIG FAST? DIG FAST, I like to use these particular words associated with them because they kind of get at the secondary symptom criteria in DSM.

D is for distractibility, I for increased goal directed activity. G is grandiosity, feeling like you could do things that nobody else can do, believing that you were maybe like a God. F is flight of ideas, going from one topic to the other, the set shifting in attention that typically is observed in a manic episode. A is for accelerated speech because S, which comes afterwards, is sleep. Decreased need for sleep, and T, I think of as trouble. Anything that might land a patient in trouble: indiscretion, impulsivity, hypersexual behaviors, sex, drugs and rock and roll I guess you could say. Different people use DIG FAST sort of in different variations of what I just described. I would just recommend that clinicians use one that helps them remember these symptoms and these criteria, because they can be very confusing.

It allows you to also get into the rhythm of asking these questions on a routine basis when patients present with mood symptoms. Repeat it as often as you can, because there's never a situation where asking a patient if they're manic one-and-done makes any sense. This is something that requires observation over time.

Dr Vanacore: I agree. I think that using that pneumonic or using a pneumonic to help you remember those symptoms and asking it the same way each time will really make sure that you are keeping an eye on the patient.

Dr Singh: Let's talk about our second case. Now we're talking about a 27-year-old nurse who presents with symptoms of depression, and she's a returning patient. She's had 3 episodes of depression, and she's previously been on citalopram and venlafaxine. Here she presents to your clinic. And I'd ask you, Denise, what kind of tools would you use when you're screening a patient for depression?

Dr Vanacore: So the tools that I generally use in clinical practice are the PHQ-9. And the one thing that I really love about the PHQ-9 is it's nine questions. So it's, again, pretty quick. That ninth question always speaks to any kind of self-harm or suicidality. That's always a good gauge. It's easily scored. One of the things you could do with the PHQ-9 is really embed it in your EMR, and you can have the patients do it before they even get to see you. You could see the numbers and see what things look like pretty quickly. One of the other advantages, you can track changes in responses as you're treating patients. It's been around for quite some time, so it's quite a reliable and valid tool. I really like that as one.

The second tool that I use, which I think is always important to do whenever you're trying to screen somebody to rule in MDD or major depressive disorder, is the MDQ, which is the mood disorder questionnaire. The MDQ helps to determine whether or not you should consider additional screening for bipolar episode, or that you've screened out for a bipolar episode and can go ahead and successfully treat your patient for a major depressive disorder. The MDQ is actually a 15 question tool. Thirteen of the questions are pretty straightforward because they're yes/no questions. The last 2 really talk more about the severity of the symptoms, and to give you a little bit more insight as to whether or not the patient is having a lot of difficulty with those symptoms.

Dr Singh: And in contrast to the RMS, it sounds too that PHQ-9 and MDQ are very often used in primary care settings. I love your point about the EMR integration. I think that can help practitioners out a lot to have those embedded into their workflows.

So your patient, the nurse, completes the PHQ-9 and MDQ, and screens positive on the PHQ-9 for MDD. The PHQ-9 item nine, or the suicidal question is answered no, thankfully. And she screens negative for MDQ for bipolar with a score of 6. So, what challenges do you face when differentiating bipolar disorder from unipolar depression when patients present with a unipolar major depressive episode?

Dr Vanacore: I think here it's really important to make sure that you look at not just the patient screening tools, but you really do a good clinical exam here. Because as you start to look at what the patient might be telling you, you might find that they've been on 2 antidepressants already, like our nurse has. I call these 'antidepressant misadventures.' Because patients get on them, they feel a little bit better for a short while, and then all of a sudden they develop an increase in irritability or an increase in mood liability. And then they stop the antidepressant, they feel a little bit better which bodes to making sure that you're on the right track.

Sometimes patients with MDD may have sub-threshold symptoms of hypomania, and that can often lead to misdiagnosis. When I see someone who's failed 2 other antidepressants, I start to really take a look at what other symptoms might be present. One of the things that we want to consider is family history. Have multiple relatives had other depressive or bipolar or even borderline personality disorder problems? What other family history do we have that could indicate that this might not be simple depression, such as a family history that includes bipolar disorder?

Also when we see the course of the illness, we see a much younger onset, usually before the age of 25. And so again, we see that patients who are younger, this woman has already been on 2 antidepressants and she's 27. We know that this has started at an earlier age. And the more recurrent episodes you have, the more difficult it gets to tease out the symptoms.

We also know that episodes often start and stop abruptly and that's why patients stop their antidepressants when they start to not feel well and all of a sudden the symptoms seem to disappear. Treatment response is a big one. We talked about the fact she's failed 2 antidepressants already. Sometimes we see antidepressant induced mania, which is another part of the problem.

We also see chaotic relationships with work, with social relationships; maybe they've been divorced already at the age of 27 a time or 2. Again, they also might have a comorbid substance use history, so they may be using something else. Many of these other symptoms or clues can help us either 'rule in' or 'rule out' that possibility of a bipolar disorder.

Dr Singh: I couldn't agree with you more, that a detailed patient history and being very thoughtful about the entire holistic picture besides just the symptom screening end up becoming the most critical for approximating or getting you closer to the correct diagnosis.

For this nurse, she further clarifies on the MDQ that she actually does have more symptoms when you probe further and do that more comprehensive evaluation. She also explains that she's had several residual symptoms with previous treatment that never really went away. The patient's concerned with this new diagnosis. How do you talk her through that, "Wow. We initially thought this was unipolar depression, but it turns out that it's looking more like it could be bipolar depression." That merits a different treatment plan perhaps, and some careful reevaluation of the history. What kind of tips would you suggest in terms of how we do this better, and also support this patient in a way that leads to an accurate diagnosis and treatment course?

Dr Vanacore: I think this is where we really need to spend time talking to the patient about the diagnosis. Patients are always concerned. It's kind of okay to have depression. It's kind of like that's an 'alright diagnosis.' But when we get to that bipolar disorder diagnosis, that one becomes a more stigmatizing. I'm definitely a fan of avoiding any kind of stigma in mental health because we have enough problems. But here is a good time to talk to the patient about how unipolar depression means there's just depressive symptoms on one side and bipolar depression just means you have symptoms on both sides, and it's another label that we give it. But it's treated differently, and it's important that we get to the root of it and we treat to remission just like we would if she had major depressive disorder.

This is a good time to work with a therapist as well, to help patients really understand and work with their diagnosis. I think it's important to have those open conversations with patients and provide opportunities for other education, where they can go meet other patients and see that bipolar disorder is not a life ending disease. It can be treated. It is not as stigmatizing as they think. And yes, she can have a perfectly full life and good quality of life. That's the important part.

Dr Singh: I couldn't agree with you more on the importance of de-stigmatizing. It really takes a village, doesn't it? A team approach to collaborate, both with patients but also all healthcare professionals in order for us to make progress with doing comprehensive evaluations and providing comprehensive treatment plans for patients with this complex disorder.

Dr Vanacore: I think a really good point to the team approach for mood disorders in particular is the idea that the more eyes on the patient, the better the patient care is because more people are actually taking a look at that patient's symptoms and figuring that out.

I'm a true fan of involving our pharmacists, our nurses, our therapists, our psychiatrists. I love working with our psychiatrists. They're just amazing to help with anything. We use a digital communication platform to facilitate the team approach. There's a lot of great digital tools you can use, but it's a great way to pop a quick question out to a team of people and say, "Hey, I have this patient with this, this, and this problem. This is what I'm thinking of doing. Does anybody see any red flags with that?" Digital communication platforms are a great way to ask questions and to communicate quickly and easily. Anything we can do to actually help patients really have more providers to lean on as they are going through their treatment process is really, really important.

Dr Singh: I agree.

Dr Vanacore: Thank you for being with me today and having this insightful discussion on bipolar disorder, and I want to thank the audience for participating in this activity. Please continue on to answer the questions that follow and complete the evaluation tool.

This transcript has not been copyedited.

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