10/15/2013 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 Kelly M. Rock, DNP, CRNP Identify the FNP role in managing patients with depression vs bipolar II Think “BIG PICTURE” Think episodic Think in context of history Patients with Inaccurate bipolar II wait 8- diagnosis often Inadequate 10 years for leads to treatment can correct inadequate be deadly diagnosis treatment 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! 1 10/15/2013 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 A distinct period of abnormally and persistently elevated, expansive, or symptoms is either (1) depressed mood or (2) loss of interest or pleasure. NOTE: irritable mood and abnormally and persistently increased activity or Do not include symptoms that are clearly attributable to another medical energy, lasting at least 4 consecutive days and present most of the day, condition nearly every day. Depressed mood most of the day, nearly every day, as indicated by either subjective report During the period of mood disturbance and increased energy and activity, (e.g. feels sad, empty, hopeless) or observation made by others (e.g. appears tearful). (NOTE: 3 (or more) of the following symptoms (4 if the mood is only irritable) In children and adolescents, can be irritable mood). have persisted, represent a noticeable change from usual behavior, and . 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) have been present to a significant degree: . Significant weight loss when not dieting or weight gain (e.g. a change of more than 5% of body . Inflated self-esteem or grandiosity. weight in a month), or decrease or increase in appetite nearly every day. (NOTE: In children, . consider failure to make expected weight gain) Decreased need for sleep (e.g. feels rested after only 3 hours of sleep). Insomnia or hypersomnia nearly every day . More talkative than usual or a pressure to keep talking. Psychomotor agitation or retardation nearly every day (observable by others, not merely . Flight of ideas or subjective experience that thoughts are racing. subjective feelings of restless or being slowed down) . Distractibility (i.e. attention too easily drawn to unimportant or irrelevant . Fatigue or loss of energy nearly every day external stimuli), as reported or observed . Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick) . Increase in goal-directed activity (either socially, at work or school, or sexually) . Diminished ability to think or concentration, or indecisiveness, nearly every day (either by or psychomotor agitation. subjective account or as observed by others). Excessive involvement in activities that have a high potential for painful . Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a consequences (e.g. engaging in unrestrained buying sprees, sexual specific plan, or a suicide attempt or a specific plan for committing suicide. indiscretions, or foolish business investments) The episode is associated with an unequivocal change You can then put all of the information in functioning that is characteristic of the individual when not symptomatic together to formulate a diagnosis The disturbance in mood and the change in . DSM 5 is your guide 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) Meets criteria for one or more lifetime episode(s) of a Major depressive disorder (MDD) major depressive episode (as previously defined) Cyclothymic disorder (cyclothymia) The symptoms cause clinically significant distress or impairment in social, occupational, or other important Bipolar II disorder 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 2 10/15/2013 For at least 2 years (at least 1 year in children/adolescents) there have Criteria have been met for at least one hypomanic been numerous periods with hypomanic symptoms that do not meet criteria for a hypomanic episode and numerous periods with depressive episode and at least one major depressive episode. symptoms that do not meet criteria for a major depressive episode. There has never been a manic episode. During the above 2-year period (1 year in children/adolescents), the The occurrence of the hypomanic episode(s) and major hypomanic and depressive periods have been present for at least half the depressive episode(s) is not better explained by time and the individual has not been without the symptoms for more than 2 months at a time. schizoaffective disorder, schizophrenia, schizophreniform Criteria for a major depressive, manic, or hypomanic episode have never disorder, delusional disorder, or other specified or been met unspecified schizophrenia spectrum and other psychotic The symptoms are not better explained by schizoaffective disorder, disorder. schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic The symptoms of depression or the unpredictability disorder caused by frequent alternation between periods of The symptoms are not attributable to the physiological effects of a depression and hypomania causes clinically significant substance (e.g. a drug of abuse, a medication) or another medical distress or impairment in social, occupation, or other condition (e.g. hypothyroidism) important areas of functioning. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. MDD Cyclothymia Bipolar II Prevalence 12 month prevalence in US is Lifetime prevalence 0.4-1% 12 month prevalence in US is 7% 0.8% Gender Female:Male ratio No consistent gender No consistent gender MDD Cyclothymia Bipolar II 1.5-3:1 differences in literature differences in literature No lifetime episodes Onset Likely onset puberty. Peak Usually begins in Average onset is mid 20s, At least 1 lifetime At least 1 lifetime of major depression, in 20s. Late onset common. adolescence or early though can occur earlier or episode of major episode of major adulthood later but some depressive depression depression symptoms Course Course is extremely variable Course is variable. 15-50% Course is variable develop bipolar I or II disorder No lifetime episodes At least 1 lifetime No lifetime episode of hypomania, but episode of of hypomania some hypomanic hypomania Suicide risk Suicide is risk at all times in Suicide data not available Suicide risk HIGH. 1/3 report symptoms MDD. attempting suicide Depressive episodes look exactly the same in WRONG! It’s actually very difficult! MDD and bipolar II disorder (not as severe in . WHY IS IT SO HARD? cyclothymic disorder). The only thing that ▪ Who is ever going to come into your office saying that they feel wonderful, have plenty of energy, are differentiates MDD from bipolar II disorder is incredibly productive, don’t need much sleep, and are the presence or absence of a lifetime not having any problems functioning? ▪ Depression will almost always be CC hypomanic episode! ▪ 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?? 3 10/15/2013 Tools to help identify past/present hypomania Chief complaint History of present illness Remember: think “episode” 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 Clinical interview D = distractibility/easily frustrated . Use DSM 5 criteria I = Irresponsible/erratic behavior Collateral information sources G = Grandiosity . Parents, partner, children F = Flight of ideas . Request old records A = Activity is increased Mood disorder questionnaire S = Sleep is decreased . Quick, easy, free T = Talkativeness . *This is a mnemonic for mania. May not capture hypomania! 4 10/15/2013 Not “diagnostic” for bipolar disorder. Simply Can’t I treat every depressive episode the raises level