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Kelly M. Rock, DNP, CRNP

Identify criteria for major depression and bipolar II disorder

Identify screening tools and interventions that can assist in identifying symptoms of hypomania

Identify medications that are FDA-approved to manage bipolar II disorder

Identify the FNP role in managing patients with depression vs bipolar II

Think “BIG PICTURE” Think episodic Think in context of history

Patients with bipolar II wait 8-

10 years for correct

diagnosis

Inaccurate diagnosis often

leads to inadequate treatment

Inadequate treatment can

be deadly

When a patient presents with a depressive episode, you MUST consider both major depressive disorder (MDD) and bipolar disorder (especially bipolar II disorder) as a potential diagnosis

WHY?? Because a depressive episode looks exactly the same in MDD as it does is bipolar II disorder

If you do not screen for hypomania, you will miss it!

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Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. NOTE: Do not include symptoms that are clearly attributable to another medical condition Depressed mood most of the day, nearly every day, as indicated by either subjective report

(e.g. feels sad, empty, hopeless) or observation made by others (e.g. appears tearful). (NOTE: In children and adolescents, can be irritable mood).

Markedly diminished interest or pleasure in all, or almost all, activities most of the day nearly every day (as indicated by either subjective account or observation)

Significant weight loss when not dieting or weight gain (e.g. a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. (NOTE: In children, consider failure to make expected weight gain)

Insomnia or hypersomnia nearly every day Psychomotor agitation or retardation nearly every day (observable by others, not merely

subjective feelings of restless or being slowed down) Fatigue or loss of energy nearly every day Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly

every day (not merely self-reproach or guilt about being sick) Diminished ability to think or concentration, or indecisiveness, nearly every day (either by

subjective account or as observed by others). Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a

specific plan, or a suicide attempt or a specific plan for committing suicide.

A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least 4 consecutive days and present most of the day, nearly every day.

During the period of mood disturbance and increased energy and activity, 3 (or more) of the following symptoms (4 if the mood is only irritable) have persisted, represent a noticeable change from usual behavior, and have been present to a significant degree: Inflated self-esteem or grandiosity. Decreased need for sleep (e.g. feels rested after only 3 hours of sleep). More talkative than usual or a pressure to keep talking. Flight of ideas or subjective experience that thoughts are racing. Distractibility (i.e. attention too easily drawn to unimportant or irrelevant

external stimuli), as reported or observed Increase in goal-directed activity (either socially, at work or school, or sexually)

or psychomotor agitation. Excessive involvement in activities that have a high potential for painful

consequences (e.g. engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)

The episode is associated with an unequivocal change in functioning that is characteristic of the individual when not symptomatic

The disturbance in mood and the change in functioning are observable by others.

The episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization. If there are psychotic features, the episode is, by definition, manic.

The episode is not attributable to the physiological effects of a substance (e.g. medication, ECT)

You can then put all of the information together to formulate a diagnosis

DSM 5 is your guide

Major depressive disorder (MDD) Cyclothymic disorder (cyclothymia) Bipolar II disorder

Meets criteria for one or more lifetime episode(s) of a major depressive episode (as previously defined)

The symptoms cause clinically significant distress or impairment in social, occupational, or other important area of functioning.

The episode is not attributable to the physiological effects of a substance or to another medical condition

The occurrence of the major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders.

There has never been a manic episode or a hypomanic episode

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For at least 2 years (at least 1 year in children/adolescents) there have been numerous periods with hypomanic symptoms that do not meet criteria for a hypomanic episode and numerous periods with depressive symptoms that do not meet criteria for a major depressive episode.

During the above 2-year period (1 year in children/adolescents), the hypomanic and depressive periods have been present for at least half the time and the individual has not been without the symptoms for more than 2 months at a time.

Criteria for a major depressive, manic, or hypomanic episode have never been met

The symptoms are not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder

The symptoms are not attributable to the physiological effects of a substance (e.g. a drug of abuse, a medication) or another medical condition (e.g. hypothyroidism)

The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Criteria have been met for at least one hypomanic episode and at least one major depressive episode.

There has never been a manic episode. The occurrence of the hypomanic episode(s) and major

depressive episode(s) is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder.

The symptoms of depression or the unpredictability caused by frequent alternation between periods of depression and hypomania causes clinically significant distress or impairment in social, occupation, or other important areas of functioning.

MDD

At least 1 lifetime episode of major

depression

No lifetime episode of hypomania

Cyclothymia

No lifetime episodes of major depression, but some depressive

symptoms

No lifetime episodes of hypomania, but some hypomanic

symptoms

Bipolar II

At least 1 lifetime episode of major

depression

At least 1 lifetime episode of

hypomania

MDD Cyclothymia Bipolar II

Prevalence 12 month prevalence in US is 7%

Lifetime prevalence 0.4-1% 12 month prevalence in US is 0.8%

Gender Female:Male ratio 1.5-3:1

No consistent gender differences in literature

No consistent gender differences in literature

Onset Likely onset puberty. Peak in 20s. Late onset common.

Usually begins in adolescence or early adulthood

Average onset is mid 20s, though can occur earlier or later

Course Course is extremely variable

Course is variable. 15-50% develop bipolar I or II disorder

Course is variable

Suicide risk Suicide is risk at all times in MDD.

Suicide data not available

Suicide risk HIGH. 1/3 report attempting suicide

Depressive episodes look exactly the same in MDD and bipolar II disorder (not as severe in cyclothymic disorder). The only thing that differentiates MDD from bipolar II disorder is the presence or absence of a lifetime hypomanic episode!

WRONG! It’s actually very difficult! WHY IS IT SO HARD?

▪ Who is ever going to come into your office saying that they feel wonderful, have plenty of energy, are incredibly productive, don’t need much sleep, and are not having any problems functioning? ▪ Depression will almost always be CC

▪ On top of that, who is going to think that this is ‘abnormal’ or ‘out of the ordinary’ or ‘a problem’?

▪ And if it’s only happened a time or two, who is actually going to remember it??

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Tools to help identify past/present hypomania Chief complaint History of present illness Past psychiatric history Inpatient psych admissions, specialized outpatient

treatment, past diagnoses, past med trials, suicide attempts, history of self-injury

Family psychiatric history Personal history (developmental, academic,

social)

*A psychiatric interview in specialty care would have other components

Remember: think “episode”

Clinical interview

Use DSM 5 criteria

Collateral information sources

Parents, partner, children

Request old records

Mood disorder questionnaire

Quick, easy, free

D = distractibility/easily frustrated I = Irresponsible/erratic behavior G = Grandiosity F = Flight of ideas A = Activity is increased S = Sleep is decreased T = Talkativeness

*This is a mnemonic for mania. May not capture hypomania!

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Not “diagnostic” for bipolar disorder. Simply raises level of suspicion.

Ideally, the FNP should refer the patient to a psychiatric specialist for formal evaluation, diagnosis, and treatment

Psychiatrist

Psychiatric nurse practitioner

Psychiatric clinical nurse specialist (cannot yet prescribe in PA)

Can’t I treat every depressive episode the same?

If you prescribe an antidepressant to a patient with bipolar II disorder

1/3 improve

1/3 experience no effect

1/3 show mood destabilization/worsening of condition, possibly leading to “manic switch”

None

Quetiapine XR (Seroquel XR) Quetiapine (Seroquel)

Wide variability in treatment approaches Lack of current guidelines Liability

Psychiatric providers are in the best position

to work with patients with bipolar II to find a regimen that works for them

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Refer for psychotherapy if indicated Discuss non-pharmacologic measures

Exercise regimen

Initiate pharmacologic measures if indicated

MDD treatment guidelines updated 2010 (attachment provided)

Monotherapies

1st Line • *SSRI

• *NDRI

• *SNRI

Monotherapies

2nd Line

• *Mirtazepine (Remeron)

• TCA

• SARI

• MAOI

Augmentation

• *Buspirone (Buspar)

• Lithium (low dose)

• *Benzos

• T3/T4

• Stimulant

• *SGA

• *L-methylfolate (Deplin)

Ancillary

• Cognitive therapy

• ECT

• Inpatient

• Vagus nerve stimulation (VNS)

Adapted from: Stahl, Stephen. (2008). Stahl’s Essential Psychopharmacology. Neuroscientific Basis and Practical Applications (3rd ed.). Cambridge University Press.

Screen for bipolar disorder when anyone presents with a depressed episode.

Refer positive bipolar screens to a psychiatric specialist for evaluation, diagnosis and treatment.

Decrease stigma through education Normalize patient experience Explain rationale for referral to decrease

feelings of abandonment

Bipolar II disorder is often times as difficult, if not more difficult, to manage than MDD

FDA approved medications are limited It is as much an art as it is a science I utilize traditional antidepressants with great

caution if I use them in a patient with bipolar II disorder

If I were a family NP (knowing what I know as a psych NP), I would not treat bipolar II disorder in the family practice setting

Kelly M. Rock, DNP, CRNP Family Counseling Center of Armstrong County kmrock@fccac.org