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.
TCPR: Let’s talk about mood charting, which is something we’ve been taught to do but for some reason many of us don’t do it. We provide a table of online mood charting tools for our readers in this issue. Maybe you can help us to figure out a system that works well.
Dr. Strakowski: I think mood charting is perceived as being a lot more time-consuming and difficult than it is, but in my experience it is exactly the opposite. Mood charting is the best way to facilitate an effective follow-up meeting. First, you have to find one, and I recommend the chart created by the Depression and Bipolar Support Alliance—it’s on their website, and it’s very inexpensive (http://www.dbsalliance.org). The way I sell mood charting to patients is I talk about how human beings are designed, that we tend to assume that how we feel right now is how we’ve felt for the last 30 days or more. I say, “And so if we don’t have a way of capturing this information between visits, we end up making bad treatment decisions because we’re basing it on today rather than what’s happened since I saw you last.” So we work out a simple plan that the patient is going to check a box on the chart where their mood was when it was at its worst for that day. It can be the last thing they do at bedtime. There are lots of other things they can note, such as sleep and medication. Different patients will use it to varying degrees, but the only thing I really care about is that once a day they are checking where their mood was, and that’s fairly straightforward and easy.
TCPR: Does it take a while to teach patients this?
Dr. Strakowski: No, it takes 5 to 7 minutes, and it isn’t as though we have one shot and we’re done. When they bring it back next time, if it’s not filled out correctly, we can talk about it. And over 3, 4, or 5 months, it gets easier. Then what happens is when they get good at it, they flop it on my desk and say, “Here’s my mood chart,” instead of me having to ask, “How were you the last month?” “What happened a week ago?” So that facilitates a much more efficient follow-up appointment. We can look at the graph together and say, “Well, it looks like you’ve had some ups and downs, but the overall trend is up or the overall trend is down,” and then we can move on to making decisions.
TCPR: How do patients take to mood charting?
Dr. Strakowski: In my experience, they pick it up easily; it’s not complicated. Do all patients religiously complete their mood charts? Of course not; I’m completely aware that some will be filling it in on the car ride over or in the waiting room. But at least they are paying attention and thinking about it. And over time they realize, “Hey, this helps my doctor make decisions, and I don’t have to spend all my time recounting day-to-day events. I can actually talk about what’s important to me.” So that’s how I’ve approached it, and I’ve had very good success across all ages. Patients find that it is just easier to do them than talk about why they weren’t done. So I really can’t over-recommend mood charting; it will make your follow-ups that much more efficient.
TCPR: Yes, the time constraints in our follow-up appointments are definitely challenging. What do you recommend we accomplish during these shorter visits?
Dr. Strakowski: Probably the most common mistake I see psychiatrists make when treating bipolar disorder is they’re constantly reactive. There is a tendency to pathologize even normal day-to-day variability in people’s mood, but you don’t want to be making constant medication changes and additions in response to what is probably a 2-day blip. But if you had a 30-day charting, you’d be able to say, “Well, this has happened twice and I don’t need to do anything because the trend is still towards recovery.” Of course, with patients who are acutely ill, we are going to ask about suicidality most visits. Then usually I’m building a program over time, and so I try to introduce elements of that, whether it’s focusing on sleep schedule or appetite or diet. I don’t try to do everything at every appointment. I try to think about how we can space out different pieces of what I need to know so that we’re covering them, say, over a span of 6 months.
Probably the most common mistake I see psychiatrists make when treating bipolar disorder is they’re constantly reactive. There is a tendency to pathologize even normal day-to-day variability in people’s mood, but you don’t want to be making constant medication changes and additions in response to what is probably a 2-day blip.
~ Stephen Strakowski, MD
TCPR: It’s challenging when issues arise that are more suited to be handled therapeutically, in terms of time. You want to help your patient, but you also have a lot to cover from a clinical perspective.
Dr. Strakowski: With a 15-minute med check, you have to be very clear on your responsibilities. You’re not the therapist, so you will want to make sure that someone is working with that person whenever possible because it’s a programmatic treatment. I usually have some functional metric that we’re following—work, school, etc.—and we talk about whatever treatment changes that we need to make. I tend to see 2–3 patients an hour. Once someone is stabilized, it takes me about 3 minutes with a mood chart if that patient is generally doing well. Then I’ll have time to do a little bit of cognitive therapy. If we’re focused on cognitive behavioral interventions, I can bill for both the E/M code and the therapy code.
TCPR: Can you share any types of cognitive behavioral interventions that you find particularly effective?
Dr. Strakowski: Sure. I create these 3- to 4-column charts where we look at specific upsetting events: the mood, the feeling response, the thought response. And then we do thought restructuring. With my really anxious patients, I do a lot of threat assessing. I teach them that when they’re anxious, it means their brain thinks they are in danger, and so we try to get them to acknowledge this overreaction to a perceived threat. We try to diminish how important a specific threat is and how to evaluate this to work through anxious moments.
TCPR: We have a lot of tools in our medication arsenal to treat different symptoms, and so I think there is a tendency to treat symptoms as they pop up. We can end up piling one medication on top of another, and then we have a patient subsequently on multiple meds. Any suggestions for preventing this?
Dr. Strakowski: Well, I often say that if you look at the psychiatric medication evidence base, there are a few studies with combinations of two medicines, and few if any studies with three. This isn’t like cancer care where there have been carefully developed regimens that have been tested in large groups over time. We don’t have that data, and so the instant you go from two or three multi-drug medications, you’re off the evidence base. My general rule is no more than three medications. To your point earlier, when I was training, one of my supervisors used to say, “You identify the symptoms, then you treat each one.” I disagree with that; you identify the diagnosis because trials are usually based on diagnoses, not symptoms. You use what we know is effective in a diagnostic group, realizing that if your treatment is failing, your diagnosis may be wrong. And if you do that, then there’s less of a tendency to chase symptoms with lots of drugs.
TCPR: In my own practice, I think back to the last few patients where I’ve had a lot of meds, and usually one is an antidepressant. There is always that fear: “Well, if I do discontinue the antidepressant—you know, they seem to be stable now—what’s going to happen?”
Dr. Strakowski: Right. So you work collaboratively with that in your mood charting. You say, “Look we’re going to keep an eye on this. I take it seriously.” And if it turns out that going off that med does cause symptoms to recur, you hit it right away. And it’s not likely that suddenly they’ll lose treatment response. I do this all the time with my patients. I say, “Okay, we’ve just learned you need this. Let’s look at something else.”
TCPR: Thank you for your time, Dr. Strakowski.