TCPR: Dr. Strakowski, it’s often difficult to be certain of a bipolar disorder diagnosis based on an initial evaluation. As clinicians, we’re always looking for better screening questions to quickly hone in on whether the patient has had genuine manic episodes. How do you start your interviews?
Dr. Strakowski: I generally start with two questions. First, “Has there been any period of time where you had a lot of energy to the point where you really didn’t even need to sleep more than a few hours a night?” I think that one is characteristic enough of mania that it at least gets you started. Second, “Have you had periods of either euphoria or irritability that have lasted more than a few hours?” In addition, I usually inquire about family history: “Is there anyone in the family who has been treated for bipolar disorder or hospitalized for recurring odd behavior?” If those questions come back positive, then I go through a somewhat structured interview of mania, including the DSM-5 criteria.
TCPR: Sounds like a good start.
Dr. Strakowski: That’s an important thing to realize—it is only a start. I often emphasize to clinicians that diagnosis isn’t a thing you do at the first visit and then quit. Some psychiatrists feel the need to nail down a diagnosis after a single session, which is often unrealistic, especially with bipolar disorder.
TCPR: Can you give us some other examples of phrasing questions? We commonly ask about things such as euphoria or irritability, but our patients may not really know what we mean by these descriptions in a clinical sense.
Dr. Strakowski: For the euphoria, what I say—and this is usually in the context of someone who has come in for recurrent depression—“Has there been a time where you’ve had the opposite of this kind of down period where you’ve felt really up and high or too good in such a way that people commented on it or said they thought you were acting very differently?” For a patient you may not know very well, the tricky part is determining whether it’s someone who’s depressed all the time and finally got healthy vs. someone who became manic. So again, I put the question in context of what other people have noticed such as, “When you felt better, did people say, ‘You look like you’re feeling pretty well’ vs. ‘Wow, you’re acting sort of different or strange’?” For irritability I’ll say, “Do you find that you’ve had periods where you were snapping at friends and strangers, not just your family?” Everybody argues or gets irritable with their family, so that is not very helpful for a diagnosis. Often in these first appointments, there’s a spouse or a parent who will start nodding their head, and then you can jump in and say, “Well, it looks like your wife thinks you do,” and you can go on from there.
TCPR: Aside from core diagnostic information, what other pieces of information do you like to get during the initial interview that might end up helping to manage the illness over the long term?
Dr. Strakowski: I always ask about drug and alcohol use because that’s the number one confound. Not only is that going to mimic symptoms, but it’s the one that’s going to worsen outcome. Family history for me is very important, particularly in bipolar disorder since it is highly inheritable (Strakowski S. Bipolar Disorder. New York, NY: Oxford University Press; 2014). If there is no evidence of psychiatric illness in the family, then that really questions the diagnosis in my mind.
TCPR: If you ascertain that somebody has an alcohol or drug abuse history, what do you do with that information? How does it affect your treatment?
Dr. Strakowski: I often try to determine the timing of the two disorders—did the substance use come before the mood disorder or vice versa? I will almost never wait to try to get someone sober before I treat the mood disorder; I always try to treat them concurrently. But it’s an important part of that initial conversation: “As long as you’re smoking marijuana daily, you are immediately impairing the ability of our treatment to be effective.”
TCPR: We’ve heard about the importance of a regularized daily rhythm for patients with bipolar disorder. When do you ask about that?
Dr. Strakowski: That discussion often comes during the second visit, and becomes part of the treatment response discussion. I tell people that there is reasonable evidence that maintaining a regular sleep, exercise, and activity pattern is important. There’s some evidence that patients with bipolar disorder don’t manage these things naturally without help, and so it’s part of the recovery process. I usually introduce it fairly early as part of the treatment approach rather than as a diagnostic element per se. When I talk with patients about treatment, I really position them to think about it like managing any kind of chronic major medical illness. It’s not going to be as simple as just taking a pill. They have to understand that it’s really a programmatic treatment to manage a condition that can be complicated, and rhythmicity management is part of that.