Screening for, Diagnosing, and Treating Bipolar Disorder in Primary Care

Although bipolar disorder is rare compared with major depressive disorder (MDD) among the US population, it is important to differentiate between bipolar disorder and MDD in clinical practice. This was the topic of discussion at this afternoon’s session at Practical Updates in Primary Care 2021.

Speakers Jeffery Goldberg, MD, from the Icahn School of Medicine at Mount Sinai, and W. Clay Jackson, MD, from the University of Tennessee College of Medicine spoke about bipolar disorder across the spectrum.

“On one hand, we want to be careful to screen, and not miss, bipolar diagnoses. But on the other hand, keep in mind that it’s the rarer form of mood disorders. It’s about 2% of the population,” Dr Goldberg said.

Challenges of Diagnosing Bipolar Disorder

Dr Jackson started the presentation by discussing the phases of bipolar disorder and stressed that it is not just about mood. The current Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), criteria include mania, hypomania, euthymia, subthreshold depression, and major depression.

Depression, rather than mania, is the most common presentation of patients with bipolar disorder. Comorbidity with substance use disorders, anxiety disorders, and attention-deficit/hyperactivity disorder is also common.

All patients with mood disorders should be screened for a history of mania or hypomania, because most patients with bipolar disorder who develop a depressive episode will have concomitant manic/hypomanic symptoms. Patients with bipolar I experience depressive symptoms more often (30%) than manic/hypomanic symptoms (9%).

Then Dr Jackson talked about the comparisons of bipolar and major depressive disorder (Figure 1).

“It’s more common for patients to have […] mixed features than have a full mixed episode where they may meet both the criteria for the up and the down of the episodes,” Dr Jackson said.

Bipolar Disorder Screening Scales

The speakers then went on to outline 3 different screening tools and emphasized that the tools are not intended to replace your clinical diagnosis or experience with diagnosing mental health conditions. They are a supplemental tool to help you screen for and identify potential bipolar and MDD cases.

The first tool discussed was the Mood Disorder Questionnaire (MDQ), which is a 13-item self-report measure. Dr Goldberg said that scores of 7 or higher may indicate possible cases. Dr Jackson then outlined the Rapid Mood Screener (RMS), which is a shorter (6 items vs 13 items) questionnaire that can help you differentiate possible cases of bipolar I disorder from cases of MDD.

The Bipolarity Index was also discussed (Figure 2).

The speakers again emphasized that these screeners should be viewed as “rule-out” tools that should be followed up with detailed questioning.

Latest Agents for Treating Bipolar Disorder

Treatment reduces the risk of morbidity and mortality related to bipolar disorder by a factor of 5, Dr Jackson said.

Mood stabilizers, atypical antipsychotics, monoaminergic antidepressants, and stimulants are currently approved by the US Food and Drug Administration (FDA) and are recommended to treat bipolar disorder (Figure 3).

“Not all atypical antipsychotics possess antidepressant properties in bipolar depression,” Dr Goldberg said.

For patients with manic/mixed episodes, Dr Goldberg said to “eliminate antidepressants. You don’t need gasoline on the fire.” For patients with depressive episodes, FDA-approved medications include lurasidone, cariprazine, quetiapine, olanzapine-fluoxetine combination. Other medications are currently being investigated. For preventing future episodes, evidence-based interventions include lithium, lithium plus divalproex, and other second-generation antipsychotic agents.

“Olanzapine + samidorphan was recently approved by the FDA as maintenance monotherapy treatment of bipolar I disorder, as well as the treatment of manic or mixed episodes associated with bipolar I disorder, either as monotherapy or adjunctive therapy to lithium or valproate,” Dr Goldberg said. “Lumateperone is a novel antipsychotic that has demonstrated significant improvements in depressive symptoms in bipolar I and bipolar II disorder in a phase 3 randomized trial.”

—Amanda Balbi

Reference:

Goldberg JF, Jackson WC. Bipolar disorder across the spectrum: novel screening tools and treatment options. Presented at Practical Updates in Primary Care; September 23-25, 2021; Virtual.