Journal CMEs

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Eugene D. Gorski, MD, and Kerry C. Willis, MSN, CRNP

Needs Assessment: There are often extended periods of time from symptom onset of bipolar disorder to proper diagnosis. Patients often present to a primary care physician with complaints that can suggest presence of the disorder. This article reviews the background of the disorder, common presenting symptoms, and screening methods which suggest bipolar tendencies.

 

Learning Objectives:

• Differentiate between the various identified types of bipolar disorder.
• Identify, through historical data and examination, patients at risk of suffering from bipolar disorder.
• Recognize that validated screening tools for bipolar disorder are available and appropriate for use in the primary care setting.
• Initiate appropriate referral for further testing, definitive diagnosis, and treatment for patients screening positive for bipolar disorder.

Target Audience: Primary care physicians and psychiatrists.

 

Accreditation Statement: Mount Sinai School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

 

Mount Sinai School of Medicine designates this educational activity for a maximum of 3.0 Category 1 credit(s) toward the AMA Physician’s Recognition Award. Each physician should claim only those credits that he/she actually spent in the educational activity.

 

It is the policy of Mount Sinai School of Medicine to ensure objectivity, balance, independence, transparency, and scientific rigor in all CME-sponsored  educational activities. All faculty participating in the planning or implementation of a sponsored activity are expected to disclose to the  audience any relevant financial relationships and to assist in resolving any conflict of interest that may arise from the relationship. Presenters must also make a meaningful disclosure to the audience of their discussions of unlabeled or unapproved drugs or devices.

 

To receive credit for this activity: Read this article and the two CME-designated accompanying articles, reflect on the information presented, and then complete the CME quiz. To obtain credits, you should score 70% or better. Termination date: April 30, 2008. The estimated time to complete all three articles and the quiz is 3 hours.

Primary Psychiatry. 2006;13(4):67-70

 

Dr. Gorski is physician and Mr. Willis is certified registered nurse practitioner at the Greater Hazelton Health Alliance at Hazelton General Hospital in Pennsylvania. They are both also in private practice in Sugarloaf, Pennsylvania.

Disclosure: The authors report no affiliation with or financial interest in any organization that may pose a conflict of interest.

Please direct all correspondence to: Kerry C. Willis, MSN, CRNP, 19 Banks Ave, Sugarloaf, PA 18249; Tel: 570-788-5104; Fax: 570-788-5777; E-mail: kcw0143@yahoo.com.


 

 

Abstract

Bipolar disorder has historically been one of the most difficult psychiatric illnesses to accurately diagnose. Diagnostic criteria have evolved over the past several years and have recognized milder presentations of the syndrome. These changes have allowed clinicians to include patients into the diagnostic group who would not previously have met diagnostic criteria. Primary care physicians (PCPs) are commonly exposed to the myriad of symptoms which suggest the diagnosis of bipolar disorder. Screening tools which have been refined and validated allow PCPs to more easily identify tendencies which can lead to diagnosis and eventual treatment of the various subtypes of bipolar disorder. Treatment of this psychologically debilitating disease can improve quality of life and reduce financial burden on patients, families, and the healthcare system. This article reviews existing literature on the history and diagnostic criteria for bipolar disorder, and investigates modern screening methods.

Introduction

The manifestations of bipolar disorder can be compared to the two comic and tragic masks that represent thespians. The images of these laughing and crying faces originated from Greek theater and the poet Thespis. However, the earliest documentation of bipolar disorder was not recorded by thespians but rather by Aretaeus of Cappadocia, a 1st century Greek physician.1

The spectrum of symptoms associated with bipolar disorder has been interpreted differently throughout history. The French extensively studied bipolar syndromes in the 1800s. Old descriptions of clinical symptoms by French authors, such as hypomania, cyclothymia, mixed bipolar disorders, type II disorders, rapid-cycling forms, and seasonal bipolar forms, have been recently revisited in American psychiatric literature.2 In 1899, Emil Kraepelin3 expanded upon the French research and established a broader interpretation of bipolar syndrome, which he called “manic-depressive insanity.” Kraepelin’s work was accepted throughout the world and to this day is regarded as an incisive classic.

Modern Representation of Bipolar Disorder

There has been a “neo-Kraepelinian” thought movement identified in psychiatry over the past several decades, which has sought greater reliability in diagnosis of psychiatric disorders. During this time period the concepts of unipolarity and bipolarity have advanced, and stricter diagnostic criteria have been established. Bipolar type I disorder most closely resembles the prototypic severe manic-depressive syndrome described by Kraepelin. Kraepelin recognized that there were other subtypes of bipolar disorder. Using this philosophy, a trend began within the psychiatric community to develop a broader interpretation of the bipolar syndrome to include other bipolar disorder categories. Using a more broadly inclusive interpretation of the criteria used to diagnose bipolar disorder, the prevalence of the disorder in the general population increases to approximately 5%.4

Bipolar disorder status can be described as a point within a continuum between manic behavior and depression, with an optimal disease state at the median between the two extremes. Bipolar disorder has been broken down to several different identifiable subtypes. Bipolar type I requires the occurrence of at least one manic episode in the patient’s lifetime. Bipolar type II is a milder form of the disease and is associated with hypomania.4 Bipolar type III is not yet officially recognized as a bipolar disorder state by criteria, but has been documented extensively in the literature and refers to manic or hypomanic behavior induced by antidepressant pharmacotherapy.

Primary care physicians (PCPs) have become accustomed to thinking of anxiety and depression as syndromes that exist at a point on a continuum, as exemplified in the Figure. Likewise, bipolar disorder can be described using a similar model comprised of mania and depression. The area in which the two disease states coincide represents the period where mania and depression coexist; this state is reflective of the condition known as a mixed state. It is important to note that this mixed state of disease does not occur as often in the anxiety/depression continuum, which is more linear in nature.

Patients with severe bipolar disorder may exhibit symptoms similar to those seen in schizophrenia.5 However, less severe bipolar syndromes exist, which can be quite difficult to differentiate from primary depressive syndromes and other psychiatric disorders.

The less obvious manifestations of bipolar types II and III make diagnosis difficult for the PCP. It is estimated that approximately one-third of patients diagnosed with a major depressive illness may have a form of bipolar disorder.6 A PCP who has access to a patient for years may notice subtle behavioral changes which can suggest the presence of underlying bipolar disorder. PCPs are also in the unique position, in most cases, of having access to family members of the affected patient who can provide essential information about behaviors which cannot be observed in an office setting.

A syndrome has been identified which includes characteristics of both the standard anxiety/depression and bipolar disorder spectra known as major depressive episode with atypical features.7 The atypical features of this phenomenon include irritable mood, weight gain, appetite increase, hypersomnia, leaden paralysis, and interpersonal rejection sensitivity.8 It is interesting to note that the presence of three of these features is also highly suggestive of the presence of bipolar disorder.9

Diagnosis of Bipolar Disorder

Bipolar disorder is usually diagnosed by documenting the cyclic nature of the disease, which follows the pattern of periods of mania alternating with periods of depression. However, a significant number of patients may also have mixed states, which represent combinations of depressive and manic symptoms occurring concurrently. It is uncommon for a patient with bipolar disorder to present to a primary care setting when mania is present; the majority of bipolar patients present when depression is dominant. Patients feel energized and active during manic phases, and symptoms of actual medical diagnoses may be minimized or altered during this period of time. The presence of atypical organic symptoms and altered disease states when combined with other manic symptoms may be indicative of manic phase presentation.10

The diagnosis of bipolar disorder is difficult. Periods from bipolar symptom manifestation to formal bipolar disorder diagnosis and treatment may take up to 10 years.11 One potential explanation for the lapse of time between symptom manifestation and diagnosis is the predominance of depressive symptoms when patients present to PCPs. Patients in the depressive phase of bipolar disorder may develop somatic symptoms which do not correlate with physical examination findings. Patients may also experience amplification of symptoms of previously existing medical diagnoses. They are often noncompliant with medication regimens and do not respond well to monotherapy with selective serotonin reuptake inhibitor (SSRI) pharmacotherapy. Patients in the depressive phase of bipolar disorder may also return to the primary care setting multiple times with the same complaint, having had minimal or no perceived success with prescribed treatment modalities.

A patient’s history can provide essential information which may suggest bipolar disorder presence. Patient histories may be positive for one or more of the following characteristics: depression at an early age (<14 years of age); history of drug/alcohol abuse (often due to self-treatment); and multiple psychotropic medication failure. Findings of a first-degree family member with bipolar disorder also may predispose a patient to a bipolar syndrome disorder.12 Patients taking three or more psychotropic or anxiolytic medications are also at higher risk for bipolar disorder presence, even when other psychiatric illnesses have been diagnosed. Patients taking benzodiazepine anxiolytics in progressively increasing doses over an extended period of time are also at higher risk for bipolar disorder. Anecdotally, the authors of this article also have identified a rule-of-threes with regard to increased risk of bipolar disorder. Patients who have had three or more marriages or relationships, or three or more careers, appear more likely to exhibit bipolar tendencies on Mood Disorder Questionnaire (MDQ) screening. Bipolar disorder manifestations are responsible for the inability to sustain intimate relationships or employment. The authors of this article identified no formal research to either support or refute this claim. Binge eaters and patients who have “yo-yo” pattern alternating weight loss and gain may also have underlying bipolar disorder.13 These patients lose weight dramatically during the manic phase of bipolar disorder but gain weight in the depressive phase due to gratification overeating.

Patient response to SSRI therapy can also provide information regarding the presence of bipolar disorder. First, the patient who has no response to SSRI therapy when dosage is maximized may be exhibiting bipolar manifestations. Patients may also exhibit an untoward reaction, such as sedation, when a typically activating SSRI such as fluoxetine is prescribed. Likewise, patients may experience insomnia or agitation when a sedating SSRI such as citalopram or paroxetine is prescribed. Patients who exhibit more rapid and robust responses to SSRI therapy than pharmacologically expected may also have underlying bipolar disorder.14 A patient may note dramatic improvement in depressive symptoms within 48 hours of starting an SSRI, which is atypical for most SSRIs. Clinicians should be aware of possible placebo responses to SSRI therapy. However, the authors of this article believe screening for bipolar disorder remains appropriate in patients with this presentation.

The family of a patient suspected of suffering from bipolar disorder can provide valuable information regarding the presence of mania or hypomania, which is often not elicited during the history and physical examination of the patient. The family of the patient is acutely aware of subtle changes in behavior, and can lend ubiquitous insight regarding symptom presence.

Screening tools have been refined and shortened, which make these tools practical for use in a primary care setting. The MDQ is a bipolar disorder screening tool that is practical for a primary care setting.15 PCPs should be aware that the tool merely screens for disease tendency, and is not a diagnostic tool. A positive response to seven questions is 90% specific for bipolar disorder with a sensitivity of 70%. The MDQ plays a valuable role in assessing individuals suspected of having bipolar disorder and in referring for further evaluation and potential treatment.

When the history and examination suggest presence of bipolar disorder, clinicians should expand the subjective history to include responses to the questions outlined in the Table. Positive responses to these questions indicate screening for bipolar disorder with the MDQ. If family members are available, the family members should also complete an MDQ focusing on the patient’s behavior.

Conclusion

Bipolar disorder has multiple levels of severity which make it difficult to identify in the primary care setting. Patients who present frequently for a myriad of vague somatic complaints with multiple treatment failures should be screened for bipolar disorder. Patients who self-treat with controlled substances and alcohol are also at higher risk of suffering from bipolar disorder. Patients suffering from depression who are refractory to SSRI therapy, have untoward reactions to SSRIs, and have an accelerated response to SSRI therapy, should also be screened for the syndrome, with appropriate consideration given to possible placebo effect in those patients with accelerated responses. PCPs should screen for family history of bipolar disorder and use the MDQ when tendencies for the disorder are suspected.

The MDQ is useful in the primary care setting for screening patients at risk for bipolar disorder. Patients testing positively on the MDQ in the primary care setting should be referred for more definitive testing in a psychiatric setting and pharmacotherapeutic treatment. The MDQ is a mere screening tool for bipolar disorder and should not be used for diagnosis without appropriate psychiatric consultation and further testing. PP

References

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2. Haustgen T. [Historical aspects of bipolar disorders in French psychiatry]. Encephale. 1995;21 Spec No 6:13-20.

3. Kraepelin E. Psychiatry: A Textbook for Students and Physicians. 6th ed. [Psychiatrie: Ein Lehrbuch fur Studerende und Aerzte. 6th ed.] Barth Verlag, Leipzig; 1899.

4. Akiskal HS, Bourgeois ML, Angst J, Post R, Moller H, Hirschfeld R. Re-evaluating the prevalence of and diagnostic composition within the broad clinical spectrum of bipolar disorders. J Affect Disord. 2000;59 (suppl 1):S5-S30.

5. Tam WC, Sewell KW, Deng HC. Information processing in schizophrenia and bipolar disorder: a discriminant analysis. J Nerv Ment Dis. 1998;186(10):597-603.

6. Ghaemi SN, Boiman EE, Goodwin FK. Diagnosing bipolar disorder and the effect of antidepressants: a naturalistic study. J Clin Psychiatry. 2000;61(10):804-808.

7. Benazzi F. Major depressive episodes with hypomanic symptoms are common among depressed outpatients. Compr Psychiatry. 2001;42(2):139-143.

8. Benazzi F. Sensitivity and specificity of DSM-IV atypical features for bipolar II disorder diagnosis. Psychiatry Res. 2000;93(3):257-262.

9. Benazzi F. Sensitivity and specificity of clinical markers for the diagnosis of bipolar II disorder. Compr Psychiatry. 2001;42(6):461-465.

10. Perugi G, Akiskal HS, Lattanzi L, et al. The high prevalence of “soft” bipolar (II) features in atypical depression. Compr Psychiatry. 1998;39(2):63-71.

11. Suppes T, Leverich GS, Keck PE, et al. The Stanley Foundation Bipolar Treatment Outcome Network. II. Demographics and illness characteristics of the first 261 patients. J Affect Disord. 2001;67(1-3):45-59.

12. Bowden CL. Strategies to reduce misdiagnosis of bipolar depression. Psychiatr Serv. 2001;52(1):51-55.

13. Kruger S, Shugar G, Cooke RG. Comorbidity of binge eating disorder and the partial binge eating syndrome with bipolar disorder. Int J Eat Disord. 1996;19(1):45-52.

14. Henry C, Sorbara F, Lacoste J, Gindre C, Leboyer M. Antidepressant-induced mania in bipolar patients: identification of risk factors. J Clin Psychiatry. 2001;62(4):249-255.

15. Hirschfeld RM, Williams JB, Spitzer RL, et al. Development and validation of a screening instrument for bipolar spectrum disorder: the Mood Disorder Questionnaire. Am J Psychiatry. 2000;157(11):1873-1875.