The complexities of diagnosing bipolar disorder in primary and secondary care

The complexities of diagnosing bipolar

in primary and secondary care:

what can be done?Dr. Nick Stafford

Consultant Psychiatrist LeicestershireVice Chair Bipolar UK

This meeting is organised and funded by Lundbeck LtdThe views expressed are those of the speaker and may not necessarily reflect those of Lundbeck

Date of Preparation: January 2012 UK/SYC/1201/0167

DisclosuresAstra Zeneca

Otsuka

Bristol Myers Squibb

Pfizer

Eli Lilly

Lundbeck

Servier Laborotories

GW Pharma

Bipolar UK

My Mind Books Ltd


Summary of lecture contents

Why bipolar can be hard to diagnose

Distinguishing MDD and Bipolar

The diagnostic complexity of bipolar disorder

Comorbidities

Triage, screening and tools

Initiatives – local and national


Rationale

The early detection and improved management of bipolar in primary & secondary care.


“It took 8 years to get the right diagnosis”

Credits: Dr DJ Smith, Cardiff University; Smile On Healthcare Learning Company.

Video file sent separately


The need for early diagnosis

Early intervention – better outcomes

Prevent harmful treatment

Commence psychoeducation

Improve holistic outcomes

Reduce suffering & suicide


The stages bipolar is missed

Public & Patient

knowledgePrimary

care

Hidden by co-

morbidity

Secondary care

Hidden by co-

morbidity


Patient attending - a public health issue

Public knowledge

Co-morbiditiesSymptoms

Patient Carer

Friends

Work


Strategies for early detection

Patient presentation

Depression vs. Mania

Relationship problems

Substance or alcohol misuse

Suspicion Recurrent depression Family history Antidepressant

problems

Diagnosis Knowledge of bipolar

Collaborative history

Screening tools

Referral Early CMHT Sector psychiatrist


The Bipolar Spectrum


Course and outcomes

10 year delay in diagnosis

Morbidity of illness

Suicide rate 15% (SMR – 20 ref)

Bipolar Disorder: Clinical and Neurobiological Foundations. Lakshmi N. Yatham. Wiley-Blackwell. 2010.


BRIDGE Study –The size of the problem

Archive of General Psychiatry 2011; 68: 791-799


Why is it difficult to diagnose?

“Depression-centric” primary care interview

Lack of insight in and presentation of hypomania• Ask, Collaborative history, Screen• Sticking to an initial diagnosis despite d=changes and shifts in symptoms

Clinical issues• Recurrent depression• Mixed states – diagnostic uncertainty• Axis II disorders• Co-morbidities & large overlap of symptoms with other psychiatric disorders• Overemphasising vs. neglecting the role of temperament

Public knowledge and understanding


Diagnosis of Bipolar• Manic or mixed episode for at least 7 days• Manic episode requiring hospital admission• Depressed episode at least 2 weeks

Bipolar I

• Hypomanic and depressive episodes• No full blown manic episodesBipolar II

• Symptoms of bipolar but do not meet full criteriaBipolar NOS

• Mild shifts in mood from hypomania to depression over 2 yearsCyclothymia

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (Revised 4th ed.).Washington, DC.


Challenges in the Clinical Diagnosis

Delay of diagnosis by 10 years

Complex, variable phenomenology of BD

Different• Subtypes• Mood states• Illness courses• Age-dependent presentations

Pervasiveness of depressive symptoms

Complex and confounding comorbidities


More common in bipolar vs. unipolar

• From previous GP talkFamily history

Substance abuse

Seasonality

Onset before age 25

Postpartum onset

Psychotic depression <age 35

Atypical features

Rapid on/off pattern

Recurrent MDE’s

Antidepressants associated with hypomania / mania

Brief episodes of depression

Antidepressant wear-off

Mixed depression


References to previous slide• Family History, The heritability of bipolar affective …; Arch Gen Psych; McGuffin P et al; 2003, May 60(5);

497-502• Brief episodes, More recurrent MDEs, Earlier onset, more acute onset (rapid on/off), more total episodes,

FH, hyperactivity, alcoholism, atypical features - Am J Psych; Winokur et al; 1993; Aug 150(8) 1176-81• Seasonality – J Affect Dis; Shin et al; 2005; May; 86(1) 19-25• Postpartum – Am J Psych; Viguera et al; 2011 July (ePub ahead of print)• Psychotic depression – Leyton et al. Rev Med Chil 2010 Jun 138(6) 773-9• Antidepressant wearoff – BJPsych; Li et al; 2011 Oct epub ahead of print• AD assoc with hypomania / mania – Tondo et al. Acta Psych Scan 2010; Jun; 121(6) 404-14• Mixed depression renamed agitated and retarded depressive state; Angst J; Eur Arch Psych Clin Neurosci;

2009; Feb 259(1); 55-63


The limitations of classifications of mental disorders

Poorly linked to pathophysiology

More theoric than real

More reliable than valid

Do not replace clinical knowledge & experience

Have transcultural limitations

Categorize dimensions

Might have negative impact on psychiatric education and training


DSM-IV & ICD10 - Limitations

Drug-induced mania & hypomania are excluded: problems in judging what “direct physiological consequences of a drug, medication, or somatic treatment” means

No account taken of family history, biological markers and cognition

4 day duration required for the diagnosis of hypomania and 1 week for mania may be too long

Bipolar disorder NOS may include the majority of cases, particularly in children and adolescents

Predominant polarity and seasonal pattern for manic episodes not included as course specifiers

Recurring depressions are not recognized as potential precursors to bipolar disorder

Mixed symptoms are not sufficiently characterized and are too narrowly defined

Vieta E & Phillips M, 2007; Vieta & Suppres T, 2008


Mixed States – poorly defined


Some other problems

What constitutes a family history?

What constitutes early onset depression?

Distinguishing real symptoms of elevated mood.

What are the differences between irritability, dysphoria, dysthymia, agitation & mixed states?

What constitutes impulse behaviour?

What constitutes emotional instability?

What are the temporal issues with these symptoms?

What are the temporal issues between these problems?

Poor documentation of previous history


Bipolar I Disorder

Less problematic due to the more obvious symptoms of mania

Problems

• May not recall previous manic or mixed symptoms when presenting with depression

• Index presentation in half of cases is MDD later developing into mania

• Severity of mood elevation may be inconclusive• Treatment emergent affective switch with antidepressants


Bipolar I Disorder – other problems

Prominent psychotic symptoms may suggest:

• Schizoaffective disorder• Schizophrenia• Longitudinal course (chronic vs. recurrent) initially remains to unfold

Slower resolution of psychotic symptoms when treated with mood stabilisers may lead to diagnosis of schizoaffective disorder

Spectrum of bipolar to schizophrenia with schizoaffective disorder being an intermediary condition


Bipolar II Disorder

Hypomania may be more challenging to diagnose

Hypomanic episodes must not be severe

They must not entail:• Psychosis• Hospitalisation• Severe impairment of occupational or psychosocial function• Function may be enhanced


DSM-V Taskforce


DSM-V Specifiers, draft


ISBD Taskforce on Bipolar Depression


Probabilistic (Dimensional) Components

Bipolar I disorder

Bipolar II disorder

Bipolar disorder NOS

Major Depressive disorder II (highly recurrent, antidepressant resistant subgroup)

Major depressive disorder I (minimally recurrent, antidepressant-responsive subgroup)D

imen

sion

al m

ood

diso

rder

s sc

ale

tota

l sco

res

100

0Sachs 2004


Bipolarity IndexI. Episode characteristics (DSM-IV-TR)

Mania; hypomania; cyclothymia

II. Age of onset (non-DSM)Especially 15-19 years

III. Illness course/associated features (non-DSM)Recurrence and remission; comorbidity

IV. Response to treatment (non-DSM)Mood stabilisers – effectiveAntidepressants – ineffective; adverse effects

V. Family history (non-DSM)Bipolar; recurrent unipolar

Sachs 2004Date of Preparation: January 2012 UK/SYC/1201/0167

Predominant Polarity


Predominant Polarity


Psychiatric differentialsAxis I Axis II

Major Depressive Disorder Emotionally unstable PD

Delirium Histrionic PD

Dementia

Substance-related disorder

Schizophrenia

Schizoaffective disorder

Delusional disorders

Psychotic disorder NOS

Cyclothymic disorder

Factitious disorder

Malingering

ADHD

Conduct disorder

New Oxford Textbook of Psychiatry. Oxford University Press. Author(s): Gelder, Michael et al.Date of Preparation: January 2012 UK/SYC/1201/0167

Bipolar can look like:• Functional mental illnessesRecurrent Depression,

Anxiety

• Emotionally unstable / borderline typesPersonality disorder

• Chronic or intermittent useSubstance and alcohol misuse

• Chronic stress & psychosocial problemsNormal human emotion

New Oxford Textbook of Psychiatry. Oxford University Press. Gelder, Michael et al. 2010Date of Preparation: January 2012 UK/SYC/1201/0167

The broad range of comorbidities

Anxiety disorders

Panic disorder

Simple phobia

Social phobia

GAD

OCD

Sleep disorders

PTSD

Substance misuse

Alcohol misuse

Substance misuse

Childhood mental health

Childhood bipolar

Conduct disorder

ADHD

Personality disorders

Cluster B

Borderline

Emotionally unstable

(Eating disorders)

New Oxford Textbook of Psychiatry. Oxford University Press. Gelder, Michael et al. 2010.Date of Preparation: January 2012 UK/SYC/1201/0167

Comorbid disorders – some figures


Systematic screening and diagnosis

Routine use of collateral information

Use of screening tools and diagnostic criteria

Additional information – range of sources

In secondary care there is a need for more use of structured diagnostic interviews


Gate screen – EMIS/Systm1 & desktop


Structured Data Entry for Mood Disorders Care Pathways - Systm1


Suspicion – When to screen?

Nature of depressive episodes

(laminate)

Personal & work

relationships

Patient asks if they have

bipolar disorder

Patient’s loved one

has concerns

• Family history may be any mood disorders or alcohol or substance misuse

Family history

• Hypomanic symptoms may be missed by patient

Multiple mood

episodes

Jules Angst et al. Archives of General Psychiatry 68 (8), 2011.


3 stage strategy

Familiarise yourself with bipolar depression characteristics• Utilise a desktop laminate or equivalent tool

Obtain a collaborative history• Friend / loved one / anyone that knows them well

Screen using self administered HCL-32• Patient completes & clinician (MHF) refers


Routine use of collateral information

Useful as patient may be unable to distinguish between hypomania and normal mood

Patients are sensitive to reporting depressive symptoms

Collaterals are more sensitive to reporting symptoms of elevated mood

More important in Bipolar II and Bipolar NOS


What we can screen with

Mood Disorders Questionnaire (MDQ)• Performs well with severe bipolar in secondary care (bipolar I)

Bipolar Spectrum Diagnostic Checklists (BSDS)• Performs well with bipolar II disorder

Hypomania Checklist (HCL-32)• Performs well with both bipolar I & II disorder

Hirschfeld RM, et al. Am J Psychiatry. 2000;157:1873-1875.Nassir Ghaemi S et al. J Affect Disord 84 (2-3) 2005: 273–7.Angst J, et al. J Affect Disorder. 2005 Oct; 88(2): 217-33.


Importance of screening tools

Increasing evidence that systematically asking about hypomanic symptoms significantly increases the rate of picking up bipolar disorder

One recent study showed that of 168 patients originally diagnosed with MDD 61% went on to be diagnosed with bipolar II disorder after a structured screening tool was used

Self-rated screening tools have also been shown to be effective in picking up hypomania which otherwise might go undetected.

Hadjipavlou G. et al. Can J Psychiatry. 2004 Dec;49(12):802-12.


http://www.yellowcard.gov.uk/

Summary - Considering Referral

Family history

Recurrent mood episodes

Early onset of depressive symptoms

Any alcohol or substance misuse

Repeated relationship problems

Repeated occupational problems

Jules Angst et al. Archives of General Psychiatry 68 (8), 2011.Date of Preparation: January 2012 UK/SYC/1201/0167

Other future directions in diagnosis

National bipolar awareness day 2012 (March)• Led by Bipolar UK• Predominantly aimed at GPs• Secondarily aimed at general public

Cognitive impairment

Function brain imaging

Genetics


Online Learning Resources

Doctors.net.uk• Learning module: The early detection and

treatment of bipolar disorder. N Stafford 2012• CPD accredited

Cardiff University• http://www.beatingbipolar.org/primary_care_pract

itioners/


http://www.beatingbipolar.org/primary_care_practitioners/

http://www.beatingbipolar.org/primary_care_practitioners/

Thank you for listening

Slides available by e-mailing:[email protected]


Health & Medicine

The complexities of diagnosing bipolar disorder in primary and secondary care