Transcript

Bipolar depression is frequently misdiagnosed

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Intra-Cellular Therapies Video Series

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What can we, as clinicians, do to better identify patients with bipolar depression?
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Intra-Cellular Therapies, Inc. is sponsoring this video presentation. The speakers are presenting on behalf of the company and have received compensation for these services. The speakers are presenting information that is consistent with FDA guidelines.
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Heather Luing and Rakesh Jain are seated facing the camera. A TV screen with the ITCI logo is behind them. A turquoise background appears on screen with white copy outlining both doctors' credentials.
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Heather Luing, MD
Medical Director
Florida Center for TMS
Medical Director, Mental Health Unit
Flagler Hospital
St Augustine, Florida
(Dr. Heather Luing)
Today we're here to talk about how we, as clinicians, can better identify patients with bipolar depression. I am Dr. Heather Luing, Medical Director, Mental Health Unit at Flagler Hospital in Saint Augustine, Florida, and as a provider who actively diagnoses and manages patients with bipolar depression, I am excited to share my insights today. But I will first turn it over to my colleague, Dr. Rakesh Jain, who will kick us off by sharing his thoughts on this important topic.

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Rakesh Jain, MD
Clinical Professor, Department of Psychiatry
Texas Tech University School of Medicine
Midland, Texas
Private Practice
Austin, Texas
(Dr. Rakesh Jain)
Well, thank you, Dr. Luing, good to be with you. Hi, my name is Dr. Rakesh Jain, and I am a Clinical Professor in the Department of Psychiatry at Texas Tech University School of Medicine in Midland, Texas, and I too, am excited to share my clinical insights and experience regarding why patients with bipolar depression are so often misdiagnosed, the consequence of misdiagnosis, and how we, as clinicians, can better identify bipolar depression in patients. The fact is that depressive episodes of bipolar I and II can look clinically identical to major depression.

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(Dr. Rakesh Jain)
This is why I feel that one of the great tragedies of modern psychiatry and medicine at large, is that the vast majority of patients who actually have bipolar depression spend about 5 to 10 years of their lives with the wrong diagnosis. But why? The first part of the "why" has to do with the confusion around the depressive episodes. One of the big problems is we don't always consider bipolar disorder when we see a depressive episode. It would be incredibly useful to follow the DSM-5 for major depressive disorder, or MDD, which recommends that bipolar disorder be proactively ruled out in order to make a diagnosis of MDD. The second issue is that our techniques for detection tend to be suboptimal. We need to go further and find out more, by looking into patients' family, clinical, and treatment histories, for example. When taking patient histories, remember that patients can often be unreliable historians. If they are not offered direct, patient-centric questions, then very often, their answers don't tell the full story. So, taking a thorough history and asking the right, open-ended questions is critical, such as "Can you describe recent days where you have noticed abnormally and persistently increased activity or energy levels?" or "Do you have a family history of bipolar disorder and if so, can you explain this further?"

Dr. Luing, how do you approach identifying and diagnosing patients with bipolar depression?
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(Dr. Heather Luing)
Probably the hardest, and most important thing that I do as a psychiatrist is making the appropriate diagnosis, and using the DSM is an integral part of that process. One thing I frequently tell my colleagues is, just because a patient may be referred to me with a unipolar depression diagnosis, that doesn't mean I'm gonna stop probing to see if any of those symptoms of mania or hypomania develop over time. The reality is, for most of our patients with bipolar depression, the depression symptoms are the first thing that they experience, and they may go years before it becomes really clear that they've had mania or hypomania. So, I think remaining vigilant and open with diagnosis is the key to trying to identify these symptoms earlier and ultimately, obtain that accurate diagnosis so that patients can get the appropriate treatment that they need.

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(Dr. Rakesh Jain)
Well said. I completely agree, Dr Luing. It's never too late to revise a diagnosis based on evidence, especially if that evidence is corroborated by patients and/or their family members. We know there are many ways to help obtain that accurate diagnosis and there are some very specific techniques you can use.

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(Dr. Rakesh Jain)
For example, there are tools such as the mood disorder questionnaire, the rapid mood screener, and the Bipolar Spectrum Diagnostic Scale, which we often use to detect bipolar disorder when a patient is presenting with depressive symptoms. Additionally, I ask patients about the "here and now" and also obtain a thorough history. I've often told my residents, why do we call ourselves psychiatrists when essentially we are medical archeologists? We hunt for fossils in the past of a patient's life, and the fossils that we are digging for, looking for, uncovering, sifting through all the dust, are of course the hypomanic and the manic symptoms.

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(Dr. Heather Luing)
Talking with your patients and obtaining that thorough history is invaluable; asking patients the right questions can help elicit whether the symptoms align more closely with bipolar depression or an alternate diagnosis. Take a detailed evaluation, including a family history, understand those historical factors, and get to know when their symptoms first began. Another thing I often look for is how patients responded to a previous treatment.

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(Dr. Heather Luing)
There's a lot of things that we can do to give me clues when I'm going through that evaluation. I really think it's that thoroughness in the evaluation that is key, being vigilant and realizing things can change over time, that'll help ensure your patients have the most accurate diagnosis at every moment in time.

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The camera cuts to a frontal view of the speakers. Dr. Jain is speaking. The camera periodically cuts between the frontal view and a close-up of him speaking.
(Dr. Rakesh Jain)
Very well said. How does all of this come together in practice? I'll give you an example. A 31-year-old patient comes to my practice presenting with a lifelong history of anxiety and depression. It was her first visit with a psychiatrist. Several years ago, my approach with her would have been, I see depression, I see generalized anxiety disorder, let's diagnose her and go on from there. But the approach I would take now comes from wisdom gained through years of clinical experience. I would tell her what I detected was a depressive episode, but in order to get to the diagnosis, I need to take a thorough history. And I would also want to talk to her family, because my main goal with her was to ensure I wasn't missing bipolar disorder and particularly in her case, bipolar type II.

So, what is the learning here? When you see a depressive episode, dig further for a current or a past history of either a hypomanic episode or a manic episode, which can then help lead to a diagnosis of bipolar depression.

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The camera cuts to a frontal view of the speakers. Dr. Luing is speaking. The camera periodically cuts between the frontal view and a close-up of her speaking.
(Dr. Heather Luing)
That's a good example. And it shows why spending the time with patients and engaging them is so important. I really consider myself an educator of patients. If I'm starting a patient on a medication and I have concerns that the patient could potentially have bipolar depression, I'll talk to them about things to look for and red flags for them to be aware of. I want to make sure that I'm always keeping that open dialogue with patients so they'll come to me if they have any kind of unusual experiences or symptoms, like agitation or difficulty sleeping, among others. And sometimes seeing how patients respond to different classes of medications can help with the diagnostic process. Meaning if they are not responding well to antidepressants for example, their depressive episodes could very well be linked to bipolar disorder and not unipolar depression.

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The camera cuts to a frontal view of the speakers. Dr. Jain is speaking. The camera periodically cuts between the frontal view and a close-up of him speaking.
(Dr. Rakesh Jain)
And that is exactly right. The one cardinal rule I try and remember every single day is that major depression is not a diagnosis of inclusion. Major depression, in fact, is a diagnosis of exclusion, as per the DSM. One does not get to a diagnosis of major depression until you proactively walk through the gates of bipolar disorder to check out whether it is there or not. Only then do we make that diagnosis. And one final word of advice to my colleagues: humility is really important. I cannot tell you how often I have examined a patient and focused on the depressive episode rather than obtaining a thorough history. A diagnosis of bipolar disorder is not a static event; it's a dynamic event and thus, it's a process.

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The camera cuts to a close-up of Dr. Luing speaking. The camera periodically cuts between the frontal view and a close-up of her speaking.
(Dr. Heather Luing)
I could not agree more. Something that I think about frequently because I treat a lot of patients with very difficult-to-treat depression, both unipolar and bipolar, is that even though these diagnoses can be very similar, the reality is we know they respond very different to treatment. When I have patients who experience suboptimal response to antidepressant medications or the occurrence of an antidepressant-emergent hypomania, that is a consideration to dig further for a possible bipolar diagnosis.

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© 2022 Intra-Cellular Therapies, Inc. All rights reserved.
US-UNB-2200059 06/22
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(Dr. Heather Luing)
Overall, we know that depressive episodes feature prominently in bipolar disorder. Thus, it's our job as clinicians, or as medical archaeologists as Dr. Jain alluded to, to ensure we're doing our due diligence to obtain a thorough family, symptom, and treatment history to help differentiate bipolar depression from unipolar depression. Thank you for joining us.