TCR: Dr. Baldassano, as the Director of the Bipolar Outpatient Clinic of U Penn, how many patients with bipolar disorder do you typically evaluate in a given week?
Dr. Baldassano: About 80 patients a week, and that would include consultations, patients referred directly to me, and patients that I see in supervision with U Penn residents.
TCR: Are most of the patients referred to you already given the diagnosis of bipolar disorder?
Dr. Baldassano: Often not. Often, these patients are referred because there is some confusion about the correct diagnosis, and so I am often trying to distinguish among several different possible diagnoses, like borderline personality disorder, agitated depression, or cyclothymia.
TCR: With your wealth of experience, could you share with our readers your approach to diagnosing bipolar disorder in some of these more confusing presentations?
Dr. Baldassano: Sure. Often, the way I approach this problem is by asking patients to remember what was the most severe period of mania or hypomania that they can remember, and then I’ll keep referring back to that specific period as I ask questions pertaining to the DSM-IV diagnostic criteria.
TCR: So you find that you get a better diagnostic yield if you specify the most “severe” period?
Dr. Baldassano: Definitely.
TCR: How do you approach the patient who says that their mood fluctuates and is rapidly changeable?
Dr. Baldassano: I try to identify a pattern in one cycle. If a patient is reporting a cycle of every couple of days, I’ll ask something like, “you’ve talked about these frequent periods where you felt like your mood and energy were high and your thoughts were going quickly; have you noticed that there is a pattern after these symptoms resolve? What is your mood like then?” I find, invariably, that bipolar patients will report that their mood then becomes much more severely depressed.
TCR: How do you incorporate questions about family history in your evaluation?
Dr. Baldassano: A family history of suicidality is a marker of severe affective illness in the family. And interestingly, I’ve found that if you ask patients generally about a family history of depression or bipolar disorder, they may say there isn’t any, but then when you ask specifically about a family history of “suicide,” they say, ‘Oh yes, my grandmother committed suicide’ for example.
TCR: When you ask patients about episodes of mania, how do you phrase your questions?
Dr. Baldassano: I’ll say, “You mentioned that there were a couple of days back last month where you felt that your mood was high. Can you describe for me what that was like.” And they describe it. Then I’ll say–and this is a very important question to ask in these patients–“Are you telling me that your mood was high, above normal, or just better than the bad? Because I know you have lots of depression, we’ve talked about that.” You need to ask this because otherwise you may end up falsely labeling a normal non-depressed mood as a “high” mood.
TCR: And then how do you proceed?
Dr. Baldassano: And then I’ll say, “During that period, did you also find that you had lots of ideas going through your mind? Were those good ideas going through your mind?”
TCR: So you don’t tend to ask about “racing thoughts.”
Dr. Baldassano: To me, “racing thoughts” is not a very specific symptom. I find that almost 100% of patients will say they have racing thoughts, especially anxious patients who are ruminating. So I almost never use that term in my evaluations. Instead I say, “Do you find that your mind is accelerated, do you feel like your mind is in 5th gear and you can’t slow it down?” Then, if patients say yes to this, I’ll distinguish it from anxious thinking by asking, “You say you have a sense that your mind is going quickly; is it that you’re worrying or ruminating about something over and over again?” This is not to say that bipolar patients never experience ruminative worry, but true racing thoughts of bipolar patients is not just ruminative worry.
TCR: Is that true even for patients who have a mixed manic episode?
Dr. Baldassano: In my experience, yes. Even dysphoric manic patients will report that their thoughts are accelerating with lots of ideas rather than just worrying about things over and over.
TCR: What else do you ask to nail down the diagnosis of mania?
Dr. Baldassano: When I ask about talkativeness, I’ll say, “During the period we’re referring to, did you have the sense that it was hard to stop talking once you started talking? Did you find yourself interrupting people?” A lot of times I’ll ask patients if others noticed the talkativeness.
TCR: How to you evaluate increase in activity or restlessness?
Dr. Baldassano: I’ll ask, “During that period, did you have the sense that you wanted to keep moving or that you were physically uncomfortable if you were just sitting still? Did you sense that you were very fidgety?” And when I ask about projects, I’ll say, “Did you find yourself much more active than usual?” If they say yes, I’ll ask them to describe in more detail what that was, because by itself, this is not a particularly specific question. After all, anyone who’s feeling better than depressed is going to find themselves much more active. So I might follow up with, “If I had been with you, would I have found you to be much more active than is normal for you?”
TCR: What about grandiosity?
Dr. Baldassano: I’ll ask, “During that period, did you have a sense that you were smarter or more attractive than others, or did you have the sense that you could accomplish a lot more, or that you were much more capable and more confident, above what is normal for you at your baseline?”
TCR: How do ask about high risk behaviors?
Dr. Baldassano: I’ll say, “As you look back over that period, did you recall doing anything that could have caused trouble for you or your family? Did you find yourself involved in doing things that you wouldn’t ordinarily do? Things that you look back on now as injudicious or risky?”
TCR: We don’t have much space left here, but I’d love to hear what your personal algorithm is for initiating treatment in your bipolar patients.
Dr. Baldassano: For patients with bipolar type I, especially if they have had frequent manic episodes or episodes with psychosis, I will usually recommend lithium, Depakote, and less commonly, Tegretol.
TCR: So you recommend the tried and true, yet higher side effect agents, to people who, when they get ill, really get into trouble.
Dr. Baldassano: Right. Now, if I have a bipolar type 2 patient, I am less conservative. I think Lamictal is a great option-it’s clearly showing efficacy in the treatment of bipolar depression and now we have new data supporting maintenance treatment. So I have no problems starting a bipolar type II patient on Lamictal monotherapy. I would also consider Trileptal in these patients. While Trileptal has no controlled data supporting its use in bipolar disorder, it is closely related to its parent compound, Tegretol, and in a bipolar type II patient I’m often willing to prescribe Trileptal in order to avoid the side effect burden of the other agents. As for the other novel anti-epileptics, at this point I’m hesitant to prescribe them as monotherapy.I think we all learned a lesson from Neurontin, that just because an agent is an anti-epileptic, this does not necessarily mean that it works for bipolar disorder.
TCR: So, if you’re treating a bipolar II patient, you’ll be more comfortable using an agent with less robust clinical data.
Dr. Baldassano: Absolutely, and that’s also true for some of the milder cases of bipolar type I.
TCR: What about adjunctive use of these meds?
Dr. Baldassano: I often use novel anticonvulsants in my bipolar patients with comorbidity. So for example, if a bipolar patient has migraines and PTSD, Topamax is a good option. In anxiety disorders, I might use Neurontin or Gabitril. For weight loss, I’ll consider Zonegram or Topamax.