TCPR: Dr. Baldassano, it’s great for generalist psychiatrists to talk to an expert in bipolar disorder because, let’s face it, it can be a tough and confusing diagnosis, and deciding on treatment isn’t always easy either. How much of your time is spent treating patients with bipolar disorder?
Dr. Baldassano: Quite a bit of it. At UPenn, I’m the director of the bipolar outpatient clinic and co-director of our mood disorder consultation service. I see patients with bipolar disorder and educate residents through hands-on teaching. We follow over 500 patients with bipolar disorder, often seeing patients who are relatively refractory to treatment.
TCPR: I’m guessing that many of the patients you see come into the clinic with a diagnosis of bipolar disorder already?
Dr. Baldassano: Often that’s true, but even when patients come in with the diagnosis, an important part of my job is to review their history and not make the assumption that they have the disorder. Just because they’ve carried the diagnosis in the past doesn’t mean they actually have it.
TCPR: So how does one go about doing a world-class evaluation for bipolar disorder?
Dr. Baldassano: You have to be as systematic as possible. Before we talk to patients, we have them fill out some forms that are useful. These include a diagnostic screening form, the Mood Disorder Questionnaire (MDQ), three symptom scales—the Beck Depression Inventory, the Beck Anxiety Inventory, and the Quick Inventory of Depressive Symptomatology—and finally, and very importantly, we’ve created a medication history form that allows them to quickly circle all the meds they’ve been on in the past [Editor’s note: This form is available at http://bit.ly/1rTgHyu]. It may sound like a lot, but patients can fill these out in the waiting room and it takes them less than 10 minutes.
TCPR: What sorts of questions do you begin with in order to ascertain patients’ diagnoses?
Dr. Baldassano: I start with the usual things, “Why are you here? Are you coming here for ongoing care, or consultation?” and then I always ask, “What diagnosis have previous physicians given you?” and if they say bipolar, my first question is often, “Well why did they diagnose you with bipolar?” Because the answer to that question can really help with the rest of your interview. They might say, “I was in the hospital after a manic episode,” and then you would go right to that episode and ask about that, which helps very quickly to identify if the patient has bipolar. But if they’re not sure—which is more common than you’d think—they’ll often come in and say, “Well I don’t know, someone diagnosed me with this, but I don’t know why.”
TCPR: Where do you go from there?
Dr. Baldassano: At that point I will start by focusing on previous depressive episodes. I’ll go through a structured clinical interview, starting with, “Have you ever had an episode where you felt sad or down for most of the day for nearly two weeks?” Then we’ll go through all the DSM-5 symptoms and ascertain that they’ve had a depressive episode. Then I want to know how many episodes of depression they’ve had, and a lot of times patients will say, “I’ve been depressed my whole life,” and I say, “Really? Let’s talk more about that. Have you ever had a period of two months or so when you felt better than that?” And you’ll often find that although patients perceive these as one long episode, if you persist, you discover that there were actually periods of inter-episode recovery. Another way I’ll put it is: “Over the past two years what’s the longest period your mood has been well or normal?” My goal here is to avoid the “snap shot” and attempt to put together an entire photo album. I want to understand their longitudinal course. I’m trying to figure out how many depressive episodes they’ve had, and what percent of time they’ve suffered from depression. Now it’s possible that they’ve in fact had a two-year depression, but that is unusual. After I ask about depression, I’ll go through a similar string of questions for mania, and in this case I try to focus on whether their periods of mania really interfered with their functioning (which would qualify them for bipolar type 1) or whether they were milder hypomanic episodes, which would imply bipolar type 2.
TCPR: Does it really matter what kind of bipolar you diagnose?
Dr. Baldassano: For research it does, but even clinically it can have an impact. For example, if the mood elevations are milder and had little impact, I would be more likely to prescribe lamotrigine (Lamictal) as monotherapy—as it has more evidence for preventing depression than preventing manic episodes, and its side effect profile is good.
TCPR: Does a bipolar 2 diagnosis also make you more comfortable prescribing antidepressants, because you might be less concerned about the consequences of triggering a hypomanic episode?
Dr. Baldassano: Not really. My main qualm about using antidepressants in type 2 is a lack of efficacy rather than a manic switch. That being said, I don’t often use antidepressants in either type 1 or type 2.
One of my favorite go-to questions is, “Do you feel like the Energizer bunny but you have nowhere to go?” If a patient acknowledges that, I’m more likely to suspect bipolar.
~ Claudia Baldassano, MD
TCPR: What about patients with other syndromes, like anxiety or substance abuse. How do you disentangle these kinds of symptoms from bipolar disorder?
Dr. Baldassano: Let’s start with anxiety, because anxiety is the single most common comorbid condition in bipolar patients. It certainly adds a layer of complexity. I get referrals from anxiety disorder clinics and find that patients who were diagnosed with anxiety actually have bipolar, but it goes the other way too—patients come to me with a bipolar diagnosis and it’s actually anxiety.
TCPR: Which comorbid anxiety disorder muddies the diagnosis the most?
Dr. Baldassano: Probably generalized anxiety disorder (GAD). These patients will describe racing thoughts and feeling restless, and many clinicians will not probe deeply enough when they hear about “racing thoughts.” They’ll jump right to manic symptoms. But patients with GAD may have racing thoughts that sound more like anxious ruminations. To clarify, I’ll ask about symptoms such as irritability, sleeplessness, and feeling hyper. One of my favorite go-to questions is, “Do you feel like the Energizer bunny but you have nowhere to go?” If a patient acknowledges that, I’m more likely to suspect bipolar.
TCPR: Any tips on diagnosing bipolar disorder in substance abusers?
Dr. Baldassano: My rule of thumb is to refrain from making the diagnosis until there is a period of sobriety. For example, I recently saw a patient with a history of cocaine abuse. He had been off drugs for several months and when I evaluated him he had clear cut hypomania, was sleeping less, and feeling good; his thoughts were racing, he was more likely to want to spend money. I saw him two weeks later when his mood dropped into a depression, and he said he was more likely to want to use cocaine during depression. In that case I felt pretty certain that the primary disorder was bipolar disorder, and the secondary diagnosis was cocaine abuse—but it can be challenging to make these distinctions.