Bipolar disorder is not what it used to be, and if you’re practice is in need of makeover, tune in. 

Publication Date: 7/10/2023

Duration: 30 minutes, 43 seconds

Transcript:

CHRIS AIKEN: Welcome to the Carlat Psychiatry Podcast, keeping psychiatry honest since 2003. I’m Chris Aiken, the editor in chief of the Carlat Report.

KELLIE NEWSOME: And I’m Kellie Newsome, a psychiatric NP and a dedicated reader of every issue.

Last month we went to the International Society of Bipolar Disorders Conference in Chicago. That’s right, Chicago. It was the first time the group has met in person since the pandemic. We even got to meet a few of our podcast listeners there which was certainly one of the highlights. This conference is different from most other psych conferences in at least one way. Patients are invited in and valued for the wisdom of their lived experience. Patients presented at many of the talks, along with an eclectic mix of researchers, clinicians, and psychotherapists. 

CHRIS AIKEN: Topics ran the gamut from organoids (a new technology that uses human pluripotent stem cells cells to study the pathophysiology of disease and discover new treatments) to transcranial infrared laser stimulation, a low-dose laser therapy that is used in wound healing and was repurposed in a small study to boast cognition in bipolar disorder. There was even a paper that used the Rorschach, aka Inkblot, test to distinguish bipolar from unipolar depression. But that is not what this podcast is about. 

We’re gonna look at the big picture. Researchers are talking about ideas that weren’t even on the table when many of us completed our training – probiotics, dark therapy, and psychedelics. Today, we’ll look at which of them are ready for practice in 2023 in part one of our series on how to change the way you treat bipolar, starting with how to diagnose it.

But first, a preview of the CME quiz for this podcast. Earn CME credits through the link in the shownotes.

1. What is the rate of unrecognized bipolar disorder in patients with treatment resistant depression?

A. 20-30%

B. 30-40%

C. 40-60%

D. 80%

KELLIE NEWSOME: Bottom Line: If you regularly screen for bipolar disorder, you’ll pick it up in 30-50% of your depressed patients, and two new screening instruments: the Rapid Mood Screener and Bipolarity Index - will help you get there.

CHRIS AIKEN: Bipolar disorder is easy to miss, and if you are not screening for it in your practice already you ought to start doing so. After all, the PDR recommends screening for bipolar before starting an antidepressant. The most popular screening instrument is the mood disorder questionnaire developed in the late 1990’s by the late Robert Hirschfield. It’s a good place to start but it does a much better job at picking up on bipolar I than bipolar II, and about 70% of people with bipolar disorder have the bipolar II type, with its milder hypomanias but more prominent depressions. Two scales that detect both bipolar I and II, are the bipolar spectrum diagnostic scale, brought to us by Nassir Ghaemi, Ronald Pies and colleagues, and the hypomanic checklist 32, from the man who first proposed the bipolar vs. unipolar dichotomy, Jules Angst. Finally there’s the Sydney Bipolar Screener, a novel scale developed by Gordon Parker who first published the practice-ready version in the November 2021 issue of the Carlat Report. The Sydney Screener selected only the symptoms that distinguished bipolar depression from unipolar depression – so it’s more in line with what we’re trying to do in every day practice – and it works for bipolar I and II.

KELLIE NEWSOME: If you’re vigorously writing down all these scales, you can pause. Dr. Aiken keeps them all on his website, moodtreatmentcenter.com/measurement. Try them out and choose the one that best fits your practice, as they all have fairly similar statistical accuracy. But they also suffer from the same drawback. These are symptom checklists. And that brings us to what is new in 2023. Speakers at the conference recommended newer screening instruments that look not just at symptoms but also signs of bipolar. Symptoms can be slippery – I mean, who hasn’t had racing thoughts or high energy? Signs are more concrete, and the top four that ground a bipolar disorder diagnosis are:

1. Age of onset, typically between 15-20 for bipolar

2. Recurrence. Bipolar is more likely than unipolar to have highly recurrent depression.

3. Treatment response. Antidepressant-induced mania actually counts toward the bipolar diagnosis in DSM-5, but it’s rare to see it in practice. More often, people with bipolar disorder just say that their mood got worse on an antidepressant – more anxious, wired, agitated, or more depressed.

4. Family history.

CHRIS AIKEN: Newer screening instruments that capture this kind of data are much more accurate than the older symptomatic ones, with sensitivities and specificities in the 0.8 to 0.9 range. At the conference, they recommended the Rapid Mood Screener, developed by Roger McIntyre and colleagues, and the Bipolarity Index, created in 2004 by Gary Sachs and colleagues and later validated at my own clinic in North Carolina and other international cites.

KELLIE NEWSOME: The Rapid Mood Screener is the easiest of the two. It consists of 6 yes or no questions that the patient can answer in 2 minutes before their first visit. The Bipolarity Index is designed to be completed by the clinician during an interview, and that’s important because all of the others are just screening instruments – you can’t make the diagnosis by screening for it. You have to have a solid interview. I view the Bipolarity Index as a teaching tool – it only takes up a page, but it’s a thorough list of 50 the signs and symptoms of bipolar disorder – including post-partum mood episodes and atypical depression – each one is given a score based on how significant it is, and in the end it gives you a score from 0 to 100, single number that tells you how close your patient comes to the classic, textbook case of bipolar. 

CHRIS AIKEN: If you use the Rapid Mood Screener we recommend a slight modification to the original. Here’s why: The Rapid Mood Screener was developed through a grant from AbbVie which makes a product that is only licensed for bipolar I: cariprazine (Vraylar). The company didn’t want to run afoul of the FDA by creating a rating scale that would detect bipolar II so they intentionally limited the reach of this scale by requiring manic symptoms to last at least 7 days, just as they do in the DSM-5 criteria for mania. In my own new patient paperwork, I changed the seven to a four – since four is the cut off for hypomania.

KELLIE NEWSOME: Screening is just the first step. To diagnose bipolar disorder, you need to use a DSM-based interview, but the official structured interviews like the SCID and the MINI are costly. But don’t let that hold you back. All they do is translate the DSM criteria into everyday language. And the language that works at in New York City or Bethesda, Maryland where these instruments tend to be developed may not work best for your population. Think globally, but act locally – write the questions the way your patients will understand them.

CHRIS AIKEN: That’s what Janice Egeland and Abraham Hostetter did when they travelled to a rural Amish community to study the genetics of mood disorders they had to rethink their definition of mania. For the Amish, manic behaviors are colored by the pre-industrial society they inhabit, where the most common signs of mania are: Racing a horse and buggy too fast, buying machinery or worldly items, using the public telephone excessively, and – my favorite – planning vacations at the wrong season.

Textbooks tell us that the most common behavior in manic states is cleaning the house all night. But even that is out of date. It comes from a time when stores closed and neighbors closed their doors at night. Today, people have 24-7 access to social media and online shopping, and you’re likely to see mania show up as lengthy rambling texts and ebay binges.

KELLIE NEWSOME: One challenge with a DSM-based interview is that most manic symptoms happen during depression, as in mixed features, but the DSM only tells you how those manic symptoms look when they appear on their own. Ask the DSM what mixed features looks like and the book will guide you to read the depression criteria, read the manic criteria, and then close your eyes and imagine the two overlapping. You know, like when your patient is talking fast and slow at the same time; when they are bursting with joyous creativity and miserably depressed at the same time; euphoric but unable to experience pleasure; up all night with sparkling energy and yet somehow sleeping excessively… at the same time. This would be like a kindergarten teacher teaching kids the color green by showing them yellow and blue and asking them to imagine the two overlapping. That teacher would not last long, but the DSM committee has been doing this since 1980.

CHRIS AIKEN: In 2010 I asked Hagop Akiskal if there was a good rating scale for mixed states. He said “There isn’t, so make up your own!” I took him up on that, and have translated the DSM criteria for mania into their mixed equivalents, based on the work of Koukopolous and others as well as my own experience. I published it a few years ago in the Depression and Bipolar Workbook. We’ll end with that.

CHRIS AIKEN: Mood experts know that bipolar easy to miss, so they use all of these tools and get input from relatives. When I first started practice, I didn’t believe the high rates of bipolar disorder that people reported with this kind of structured testing, so I downloaded the tests and tried them out. After a few years, about 40% of the depressed patients in my outpatient, insurance-based private practice had some form of bipolar disorder, which is right in line with the dozen or so studies on the matter. Here’s what you can expect based on your practice setting:

In primary care depression, the rate of bipolar is 20-30%

Outpatient psychiatry, 30-40%

Treatment resistant depression and hospital settings: 40-60%

KELLIE NEWSOME: 

Now for the study of the day, A Cognitive Biotype of Depression and Symptoms, Behavior Measures, Neural Circuits, and Differential Treatment Outcomes, by Laura Hack and colleagues.

Last September, we interviewed Stanford’s Charles DeBattista, and he shared with us that cognitive problems are a marker for treatment resistance in depression, and may even be a unique subtype of depression

CHRIS AIKEN: In this new paper, Dr. DeBattista’s colleagues at Stanford have proposed a unique Cognitive subtype of depression, marked by

1) Slow processing speed

2) Insomnia

3) Poor psychosocial functioning

4) Reduced activity in the cognitive control circuits on fMRI imaging

They also had more problems with response inhibition on the go-no-go task. That’s a simple test you can do in your office. Tell the patient to do the opposite of you – specifically, they tap once every time you tap twice; and they tap twice every time you tap once. Any errors reflect a problem with the frontal lobe’s ability to inhibit responses. Your patient can test further for cognitive problems at home with the thinc-it test, a live-action app that is free online, just google the misspelled thinc-it.

This problem can occur in the young and old – in this particular study the average age was 38 and all were under age 65.

Next, the researchers looked at how this subtype faired in a large randomized controlled trial of 3 antidepressants: escitalopram, sertraline, or venlafaxine. 1 in 3 met the criteria for the cognitive subtype. As Dr. DeBattista predicted, they had a worse response, but it wasn’t all-or-nothing. 39% in the cognitively impaired group achieved remission, compared to 48% in the other group. 

Unfortunately, none of the antidepressants stood at as a better option for this cognitive subtype, but some recommend TMS therapy – which also improves cognition, and possibly vortioxetine (Trintelix) or augmentation with modafinil. Behavioral approaches that improve cognition and depression – like aerobic exercise, meditteranean diet, and CBT-insomnia – are also reasonable, but so far we lack studies in this specific, tentative phenotype.

KELLIE NEWSOME: Everyday Dr. Aiken posts a practice-changing study on his LinkedIn and Twitter feeds, @ChrisAikenMD

CHRIS AIKEN: And Kellie Newsome has a LinkedIn feed that advocates for the NP profession.

KELLIE NEWSOME: Join us next week for part II of this series where we’ll bring you 2023 updates on lithium. Earn CME for this episode from the link in the show notes, and get $30 off your first year’s subscription to the full journal with the promo code PODCAST. Your support helps us stay in the ranks of other advertising-free periodicals like Ms Magazine, Outdoor Indiana, and Cook's Illustrated.

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The Carlat CME Institute is accredited by the ACCME to provide continuing medical education for physicians. Carlat CME Institute maintains responsibility for this program and its content. Carlat CME Institute designates this enduring material educational activity for a maximum of one quarter (.25) AMA PRA Category 1 Credits^TM. Physicians or psychologists should claim credit commensurate only with the extent of their participation in the activity.