At Psych Congress 2023 in Nashville, Tennessee, Julie A. Carbray, PhD, PMHNP-BC, PMHCNS-BC, APRN, clinical professor at the University of Illinois at Chicago, and Jim Phelps, MD, emeritus psychiatrist at Samaritan Mental Health, sat down to explore the challenges of differentiating conditions like PTSD, ADHD, and generalized anxiety disorder when intertwined with depression and bipolar mixed states.
Join Drs Phelps and Carbray in an insightful discussion on the complexities of diagnosing and treating mood disorders and delve into their strategies for unraveling these diagnostic dilemmas and crafting informed treatment plans.
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Jim Phelps, MD: So Julie, you can think about children and adults. The question I would have for you is, do you think there's any way to accurately differentiate things like PTSD, ADHD, and generalized anxiety disorder when they're co-occurring with depression from bipolar mixed states?
Julie Carbray, PhD: That can be so murky. And comorbidity with those disorders, as you know Jim, is very high. And so the challenge is really trying to pull out those mood dysregulation symptoms that in and of themselves might meet criteria for bipolar spectrum disorder from those that would be very characteristic and an overlap of other disorders. PTSD and ADHD are particularly relevant across all our populations. But in children, ADHD probably is more predominant. So we can do things like use screening tools, get collateral information, look at the timeline of illness, and try to determine if we have comorbidity or if their bipolarity index might be higher due to some significant factors we know well, family history, age of onset course of illness, and if there's any cycling features as well. So taking a look at your criteria, taking a look at the mood spectrum and then using screeners collateral information, what do you think?
Dr Phelps: Well, it sounds like you wouldn't be making this diagnosis on the first visit.
Dr Carbray: Absolutely not.
Dr Phelps: And then in the adult world, especially when someone sees me for a consultation, there's often some pressure to come up with a treatment plan on that visit.
Dr Carbray: Right away.
Dr Phelps: So under those circumstances, basically I would answer my own question by saying I don't think it actually is possible to differentiate these things and reminding myself that these things aren't really things—that they're DSM criteria that are designed to help us differentiate extremes, but most patients don't present with those extremes. They present with these combinations of things. So at the end, I'm going to say, well, which of the treatments that I might consider really require calling this one way or another? And can I hedge? Is there any way to stay in the middle with the treatments that I might recommend, at least for the ones that one begins with? And then only at the end, are we going to go with an antidepressant or a mood stabilizer with antidepressant effects? That's the big division. I imagine you face the same one.
Dr Carbray: Absolutely. And I'll talk with families about that. 'What we're thinking here is there's something in the mood arena that's really challenging your child's ability to be themselves. And we're trying to figure out together what that looks like. So we'll have you keep answering some questions, monitoring mood over time. We'll continue to have these discussions. But what's most important is that we figure out where we want to go with treatment and to do that together in an informed way where we continue to see what this will look like, these murky waters. Hopefully we'll get clearer.
Julie A. Carbray, PhD, PMHNP-BC, PMHCNS-BC, APRN, is a clinical professor of psychiatry and nursing at the University of Illinois at Chicago. Dr Carbray holds her PhD (93) and Master of Science (88) degrees from Rush University, Chicago, and her Bachelor of Science (87) degree from Purdue University in West Lafayette, Indiana.
James (Jim) Phelps, MD, has worked in inpatient, outpatient, and primary care consultation and liaison programs for over 25 years, including private practice, while supporting a closet-academic’s habit of following the psychiatric literature. He is the author of A Spectrum Approach to Mood Disorders for professionals, and has written 2 other books on bipolar disorders for patients and families.
Join Desiree Matthews, PMHNP-BC, from Monarch community mental health center in Charlotte, North Carolina, as she explores the limitations of traditional antipsychotic agents and off-label therapies and uncovers the ongoing challenges of weight gain, sedation, and cardiometabolic disturbances. Nurse Matthews discusses the benefits and downsides of medications like Lumateperone and Olanzapine, and examines how to offer efficacy while minimizing unwanted side effects and adverse events like weight gain and metabolic disturbances.
Find more expert insights on bipolar disorder treatment in our Bipolar Disorder Excellence Forum.
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Psych Congress Network: What are the limitations of traditional antipsychotic agents and off-label therapies when treating patients with bipolar disorder?
Desiree Matthews, PMHNP-BC: Despite advancements in the past 10 years with second-generation antipsychotics unfortunately, many of them still come with problems like weight gain, sedation, problems with alterations in lipid, and glucose levels. So cardiometabolic side effects are still a big problem in psychiatry when it comes to our antipsychotic treatments. There are certainly off-label ways that you can manage side effects like weight gain, such as diet, exercise, and lifestyle changes. There are medications like Metformin, topiramate, and now coming to the market, more popular now are your GLP-1 agonists that certainly have approval in type 2 diabetes and obesity. The problem is these are all off-label strategies.
However, in the past few years, we've had advancements in our medications. We have medication like lumateperone, which in both open-label and the short-term studies, showed very minimal weight gain and metabolic disturbances like with lipid panel and glucose. We also have olanzapine samidorphan now.
Many of us know olanzapine, it's efficacious, it works, but a lot of us have steered away from that because of the problem with weight gain and not only weight gain early on, but unfortunately with olanzapine, with many patients, we see this trajectory of increase in weight gain over years and it doesn't stop. But now with olanzapine samidorphan, we do have the option to use that opioid antagonist, samidorphan, layer that on with the efficacious molecule, in this case, olanzapine, and we see efficacy of olanzapine in bipolar disorder, but with about a 50% reduction in weight gain risk. So that certainly now is an option for my patients, and it would make sense for me to start with, that rather than using olanzapine with the risks associated with that.
PCN: What are the cardiometabolic adverse effects that clinicians should be aware of when prescribing medications for patients with BD?
Nurse Matthews: Clinicians should be aware and talk to their patients about common side effects of antipsychotics, like cardiometabolic side effects such as weight gain, increase in lipids, as well as impaired fasting glucose. These are all known side effects, but it's important to understand that we do have newer and novel agents, where we can get efficacy, but without weight gain, without increase in your cholesterol, increase in your A1C. This is really important because we've found surveys, and even maybe in your own clinical practice, you've heard patients, wanting to stop medication because of weight gain. Weight gain can be the number one reason your patients actually stop treatment, and we all know the consequences of non-adherence.
PCN: Any final thoughts or takeaways?
Nurse Matthews: So when it comes to managing bipolar disorder, keep in mind that we have many treatment options now, and your initial treatment option can be a powerful tool when it comes to not only efficacy, but also meeting the patient's expectation in terms of being able to be adherent to medication because of side effects. We really want to make sure that with our medications, patients are doing well, they are recovering, but we also want to be sure that the tolerability is not so bad that they can't continue on with treatment. It's great to have an efficacious medication, but at the end of the day, if patients can't continue on it, they're not going to stay well.
Desiree Matthews, PHMNP-BC, is a board-certified Psychiatric Mental Health Nurse Practitioner. She received her Bachelor's of Nursing from University at Buffalo and her Master's of Nursing at Stony Brook University. She currently resides in Charlotte, NC, and practices at Monarch, a community mental health center providing telepsychiatry services to adult patients. Clinical interests include the treatment of schizophrenia, bipolar disorder, treatment-resistant unipolar depression, and drug-induced movement disorders, including tardive dyskinesia. She has provided faculty expertise and insight into the development of a clinical screener for TD called MIND-TD.
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Psych Congress Network: What are the possible cardiometabolic symptoms with conventional treatments for bipolar disorder and how can these adverse effects impact patient outcomes/adherence? How can clinicians strategize when that happens?
Rakesh Jain, MD, MPH: Metabolic side effects of many of our medications are perhaps the single greatest challenge in achieving adherence and if you don't achieve adherence you don't end up achieving anything, right? So we must face this large problem, no pun intended. It's a large challenge for us.
The smartest thing to do is to choose your medications wisely on day 1. So if you wait to correct a cardiometabolic challenge after the problem has happened, it's doable but it's so much harder. It's best to think of the strategy day 1. So choose your medications wisely. For example, if you have a patient where weight gain is a risk, but you really do think olanzapine is the right medication choice for them, what you could do is consider a medication that is olanzapine, but combined with samidorphan. So that would be Lybalvi. Wouldn't that be smart? It reduces the risk by 50%. 50% is a pretty tremendous reduction in risk. That's one strategy to employ.
The other could be that you could think of a medication with a lower weight gain risk profile. Can we think of a couple of them? Sure, I can think of cariprazine, which is Vraylar. I can think of lumateperone, which is Caplyta. Those could be effective strategies.
Now having said that, it's so important to educate patients, get the buy-in about the need to monitor for cardiometabolic issues, request a good diet, request exercise, and of course do your routine blood monitoring. When you do all that, sometimes with an augmented agent like metformin or it could be a medication that affects glucose, then success often comes our way.
I'm very glad you asked that question because it is one of the most important issues in contemporary psychiatry.
Rakesh Jain, MD, MPH, attended medical school at the University of Calcutta in India. He then attended graduate school at the University of Texas School of Public Health in Houston, where he was awarded a “National Institute/Center for Disease Control Competitive Traineeship”. He graduated from the School of Public Health in 1987 with a Masters of Public Health (MPH) degree. Dr Jain served a 3-year residency in Psychiatry at the Department of Psychiatry and Behavioral Sciences at the University of Texas Medical School at Houston. In addition, Dr Jain completed a postdoctoral fellowship in Research Psychiatry at the University of Texas Mental Sciences Institute, in Houston. He was awarded the “National Research Service Award” for the support of this postdoctoral fellowship.
In this video from on-site at NP Institute 2024 in Boston, Massachusetts, Rakesh Jain, MD, MPH, psychiatrist at Mental Wellness in Austin, Texas, tackles the complex challenge of diagnosing and differentiating bipolar disorder from other mental health conditions. Dr Jain emphasizes the importance of a thorough patient history, screening tools, and the critical role of DSM-5 guidelines. By delving into family and longitudinal history and understanding the full spectrum of symptoms, clinicians can navigate the murky waters of diagnosis with greater clarity and confidence.
For more news and insights from the 2024 Psych Congress NP Institute Meeting, visit our newsroom here on Psych Congress Network. To register for next year's conference in Orlando, Florida, from March 27-30, 2025, find more information on the meeting website.
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Psych Congress Network: What are some of the key challenges with accurately diagnosing and differentiating bipolar disorder from other mental health conditions? How can these challenges be addressed?
Rakesh Jain, MD: That's a really good question because one of the most vexing things in modern-day psychiatry is this question about differentiating bipolar disorder from other conditions. Maybe I'll pick 2, the top 2, that are confusing and perhaps shed some light on how we can clarify a murky clinical situation.
The first is, how do I differentiate bipolar depression from unipolar depression? I know it's easier said than done, but perhaps the thing to remember is the following: The symptoms of bipolar depression and the symptoms of unipolar depression look identical. Therefore, the main task you and I have is to look for a hypomanic or manic episode in the patient's history. Obviously, asking a patient, "Have you had a hypomanic episode?" is not going to work. The best thing to do is to use your scales and screeners as a starting point, and then collect family history, and most importantly, collect longitudinal history.
Always keeping in mind, DSM-5 is the North Star. Use that information, and when you do that, you do get to the right diagnosis.
The other one that you want to keep in mind is ADHD as a differential. Also a complex task. The best way to accomplish this goal is to think of them as 2 separate entities and not to let distractibility be the only symptom you're looking for. You want to look for the full cluster of symptoms from either disorder and one more time: collect longitudinal history and use DSM as your north star. You do that, success is on its way for you and your patient.
Rakesh Jain, MD, MPH, attended medical school at the University of Calcutta in India. He then attended graduate school at the University of Texas School of Public Health in Houston, where he was awarded a “National Institute/Center for Disease Control Competitive Traineeship”. He graduated from the School of Public Health in 1987 with a Masters of Public Health (MPH) degree. Dr Jain served a 3-year residency in Psychiatry at the Department of Psychiatry and Behavioral Sciences at the University of Texas Medical School at Houston. In addition, Dr Jain completed a postdoctoral fellowship in Research Psychiatry at the University of Texas Mental Sciences Institute, in Houston. He was awarded the “National Research Service Award” for the support of this postdoctoral fellowship.