Clinical Chart Review, Part 1: Assessing and Managing the Patient with Bipolar Mania
Transcript of Additional Q&A
 | MODERATOR: Roger S. McIntyre, MD, FRCPC University of Toronto University Health Network Toronto, ON Chairman and Executive Director, Brain and Cognition, Depression and Bipolar Support Alliance (DBSA) Chicago, IL Clinical Professor, Department of Psychiatry and Neurosciences University of California School of Medicine Riverside, CA |
 | Terence A. Ketter, MD Professor of Psychiatry and Behavioral Sciences Founder and Chief, Bipolar Disorders Clinic Stanford University School of Medicine Stanford, CA |
| Amit Anand, MD Professor of Psychiatry and Radiology Indiana University Bloomington, IN |
I am struggling with what I believe to be an overdiagnosis of bipolar disorder by our psychiatrist. What I believe we are actually seeing is a co-occurring disorder of major depression and generalized anxiety rather than bipolar disorder. Is it possible that anxiety can mimic or present in similar ways as mania?
Dr. Ketter: Patients with anxiety disorders also commonly have mood disorders and vice versa. Thus, comorbid anxiety symptoms and disorders need to be considered when evaluating and treating patients with bipolar disorder. And conversely, patients with anxiety disorders need be assessed for comorbid mood disorders, including bipolar disorder.(1) Symptoms possibly related to anxiety disorder that could be over interpreted as representing mood elevation include insomnia, racing (anxious rather than expansive or excited) thoughts, psychomotor agitation, distractibility, over talkativeness, and possibly even irritable mood (related to anxious concerns) and excessive goal-directed activity (related to anxious concerns). If only the above-noted symptoms of mood elevation (and none of the those mentioned below) are seen, there may be more risk of a false positive screen for bipolar disorder. While irritable depression is not a distinct subtype of unipolar major depressive disorder, irritability is associated with greater overall severity, anxiety comorbidity and suicidality.(2) Symptoms of bipolar disorder with less risk of overlapping those of anxiety disorders include euphoric/expansive mood, inflated self-esteem, decreased need for sleep (rather than mere insomnia), and engaging in pleasurable activities with a high potential for painful consequences. If any of these latter symptoms are seen, there may be less risk of a false positive bipolar disorder diagnosis.
As a psychiatrist, I am seeing more and more patients being referred to me only after they become manic which is often precipitated by use of antidepressants by primary care providers (PCPs). What is your thought on what we should be asking PCPs to use to help get patients to psychiatrists earlier in the phase of treatment?
Dr. Ketter: I believe that it would be very useful for PCPs to obtain a self-assessed and a significant other-assessed Mood Disorder Questionnaire (MDQ) for all patients about to receive their first lifetime antidepressant prescription. Also, at the time of writing any antidepressant prescription, provide the MDQ form to patients and significant others as a reminder to monitor carefully for symptoms of treatment-emergent mood elevation.(3)
You mentioned that MDQ is validated. How accurate is the scale, especially considering patients with mania may have poor insight into their illness?
Dr. Ketter: The MDQ generally has adequate specificity, but at least in some settings (such as the community rather than mood disorder clinics) it has sensitivity limitations, indicating that in some instances it may be worth considering a lower threshold than the 7 of 13 mood elevation symptoms as an indicator of the need for a thorough assessment of bipolar disorder.(3,4)
Is the Young Mania Rating Scale (YMRS) and the Clinician-Administered Rating Scale for Mania (CARS-M) diagnostic for mania, or just a measure severity of mania?
Dr. Ketter: The YMRS(5) and CARS-M(6) are measures of severity of mania in patients already diagnosed with bipolar disorder, but are not diagnostic (i.e., they are not used to establish a diagnosis of bipolar disorder).
Could you please comment on the reliability of the Bipolar Spectrum Diagnostic Scale (BSDS)?
Dr. Ketter: The validation study for the BSDS did not assess reliability (reproducibility), but did assess sensitivity and specificity.(7) In the validation study, in an outpatient psychiatric sample, the BSDS demonstrated sensitivity and specificity, comparable to that seen with the MDQ in another study in an outpatient psychiatric sample.(3) The BSDS has several components, among which "cyclicity" goes somewhat beyond DSM-IV (see table).
| BSDS Component | Signs and Symptoms |
|---|---|
| Mood Elevation/Irritability | Energy above normal, get many things done Too much energy, feel "hyper" Feel irritable, "on edge", aggressive |
| Depression | Lack of energy; extra sleep; low motivation Gain weight Feel "blue", sad, depressed Feel hopeless, suicidal Function impaired |
| Impulsivity | Take on too many activities Spend money in ways that cause trouble More talkative, outgoing, or sexual Behavior strange or annoying to others Difficulty with co-workers or police Increase alcohol or non-prescription drug use |
| Cyclicity | Mood/energy shifts drastically Mood/energy very low or very high "Normal" mood/energy, function Shift or switch in mood |
Have any of the clinical instruments for assessment of mania been validated for use by significant others, given that some patients have limited insight?
Dr. Ketter: Unfortunately, no. Your point regarding limited insight in patients is very important, and despite the paucity of systematic data to support the practice of having significant others provide clinical information regarding patients for diagnostic screening and symptom severity measurement, such an approach in clinical settings is very attractive.
References
- Freeman MP, Freeman SA, McElroy SL. The comorbidity of bipolar and anxiety disorders: prevalence, psychobiology, and treatment issues. J Affect Disord 2002;68:1-23.
- Perlis RH, Fava M, Trivedi MH, et al. Irritability is associated with anxiety and greater severity, but not bipolar spectrum features, in major depressive disorder. Acta Psychiatr Scand 2009;119: 282-289.
- 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;157:1873-1875.
- Hirschfeld RM, Holzer C, Calabrese JR, et al. Validity of the mood disorder questionnaire: a general population study. Am J Psychiatry 2003;160:178-180.
- Young RC, Biggs JT, Ziegler VE, Meyer DA. A rating scale for mania: reliability, validity and sensitivity. Br J Psychiatry 1978;133:429-435.
- Altman, E. G., D. R. Hedeker, et al. The Clinician-Administered Rating Scale for Mania (CARS-M): development, reliability, and validity. Biol Psychiatry 1994;36:124-134.
- Ghaemi NS, Miller CJ, Berv DA, Klugman J, Rosenquist KJ, Pies RW, et al. Sensitivity and specificity of a new bipolar spectrum diagnostic scale. J Affect Disord 2005;84:273-277.
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