© 2021 MJH Life Sciences and Psychiatry Times. all rights reserved.

© 2021 MJH Life Sciences™ and Psychiatry Times. all rights reserved.

Need to review a customized practical video program about bipolar disorder? We have provided you with protection.

In this customized "around practice" video program, Michael Thase, MD; Gustavo Alva, MD, DFAPA; Theresa Cerulli, MD; and Tina Matthew-Hayes, DNP, FNP, PMHNP, shared their pairs Insights on the identification and management of phase affective disorder.

"Sometimes people don't necessarily get the proper diagnosis within a period of time," said Alva, medical director of ATP clinical research in Costa Mesa, California. "According to the literature, sometimes it takes 5 to 10 years for people to make a proper diagnosis."

In order to highlight the diagnostic challenges and discuss optimal treatment, the expert team reviewed 2 interesting case episodes.

A 27-year-old woman presented to the doctor for evaluation of complex depression syndrome after the last 2 failed antidepressant trials. She has a history of attention deficit/hyperactivity disorder (ADHD), for which she took methylphenidate at a young age. As she described, her depressive episode "has happened suddenly." She was taking sertraline and escitalopram at the time of the initial evaluation; her primary care provider recently reduced escitalopram from 20 mg to 10 mg because she believed the drug might worsen her condition .

The patient’s symptoms include hypersexuality, lethargy, overeating, reactive emotions, tearing, and inattention. On the day of her first visit, she scored 16 on the Patient Health Questionnaire 9 (PHQ-9), which was in the range of moderate depression. She filled out the emotional disorder questionnaire and got a staggering 10 points. This is not the highest possible score, but it is higher than 95% of the people who participated in this list. The patient’s differential diagnosis included major depression, recurrent unipolar mixed features and bipolar type II disorder, and a previous history of ADHD. The patient did not take any mood stabilizing drugs.

"When we consider people with major depression, obviously we should consider the differential diagnosis of bipolar disorder and depression. I think this particular case is very interesting because it brings many different elements to the forefront and helps We solved the drug accident. And there may be a wrong tree that does not necessarily solve the potential problems we need to solve," Alva said.

As Cerulli explained, one of the complicating factors is the history of ADHD. "[Patients] have recurring depressive episodes with some mixed characteristics, which may be confused with factors such as ADHD responsiveness, ADHD high energy, and ADHD irritability-it is easy to ignore that this is actually a bipolar picture," she said . "We are really studying risk factors in order to be able to help determine which patients are at risk for bipolar depression, rather than unipolar depression, or just pictures of hyperactivity, anxiety and irritability. These people are often confused."

Then, the panel was asked which treatment they were most likely to start with the patient: lithium, quetiapine, divalproex, lurasidone, or cariprazine.

Matthew-Hayes chose cariprazine based on her metabolic profile, her drug treatment experience, and the FDA-approved state of depression and mania. Alva agreed and pointed out that cariprazine does not have a sedative effect, does not require food changes, and is attractive to people who may become pregnant.

A 47-year-old male investment banker with a history of manic episodes offered a second opinion on the treatment of intractable depressive episodes. His initial treatment was with lithium, which worked well, but it aggravated his psoriasis, caused him to have low-grade tremors (even with a blood concentration of 0.6 mEq/L) and caused excessive thirst. He switched to divalproex sodium, but the effect was not good. At the beginning of the attack, olanzapine was supplemented first, then risperidone, and then lamotrigine. Lamotrigine helped in previous episodes, but this time even titrating to 400 mg was not enough. Adequate trials of bupropion, fluoxetine, and duloxetine did not cause a significant drop in PHQ-9 scores even at high doses.

His symptoms include unresponsive depression, general anhedonia, and passive suicidal ideation. He has no substance use disorder and no mental illness. The interview showed that he insisted on treatment.

According to the data provided, the patient meets the definitions of refractory depression and bipolar type I depression, for which there is only one treatment indication: a combination of olanzapine and fluoxetine. Due to the metabolic risks associated with olanzapine, this treatment is not ideal.

Another strategy may be to add lithium to the current mood stabilizer combination, but patients have tolerability issues with this drug. Other options include a new generation of antipsychotics, of which quetiapine, lurasidone and cariprazine have been approved by the FDA for the treatment of bipolar type I depression.

After discussion, the group believes that cariprazine will be the best next choice. "As cariprazine is approved by the FDA for the treatment of all stages of bipolar depression, mixed phase, and manic symptoms, you will get a little assurance that you will not eventually cause manic symptoms. In fact, you may treat both and Prevent the other stages of bipolar disorder and treat the very difficult stage of depression that patients are in," Cerulli said.

In addition, the group discussed the positive role of telemedicine in the struggle to identify and treat bipolar disorder.

"This is a great opportunity to reach patients that we might not be able to reach," Cerulli said. "I found this to be a good way to see patients who are far from practice, and I now have the opportunity to work with them."

Matthew-Hayes added that telemedicine helps keep confidentiality: "Another huge benefit is that some of our patients, especially those with bipolar disorder, have more privacy."

Matthew-Hayes also suggested contacting the local National League of Mental Illness organization to help patients access the Internet at a lower speed so that they can use telemedicine appointments. Thase recommends checking the Depression and Bipolar Support Alliance, a 30-year member of the Alliance, where you can find most of the free psychological education resources.

Dr. Thase is a professor of psychiatry at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia. Dr. Alva is the medical director of ATP clinical research in Costa Mesa, California. He has also collaborated with Avanir, Otsuka, ACADIA, Lundbeck, Abbvie, Teva, Neurocrine Biosciences, Athira, Liva-Nova and Alector. Dr. Cerulli is the medical director of Cerulli and Associates in North Andover, Massachusetts. She also works with Abbvie and is a spokesperson for Vraylar. Tina Matthew-Hayes is a dual-certified nurse practitioner at the West Pennsylvania Behavioral Health Resource Center in West Mifflin, Pennsylvania. ❒