Alan "Tony" Amberg, MSN, APRN, PMHNP-BC discusses making the DSM-5 criteria for depressive episodes in bipolar disorder more digestible for providers utilizing clinical patient probes.

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Hi, my name is Tony Amberg and I am a psychiatric nurse practitioner. Today I will be speaking about how to screen for bipolar disorder using the DSM-5. We’ll unpack the criteria set forth in the guidelines in a more digestible manner and use patient probes to better understand how to use these criteria in a clinical setting.

In my experience, bipolar disorder can be difficult to diagnose since it’s characterized by manic and depressive episodes, as well as mixed features at times. Don’t forget, most people spend most of their life in depressed episodes. There may only be a few manic episodes so screening is really important.

There is something called rapid cycling but what we mean by that is not every day. What we mean by that is a person who has 4 distinct mood episodes in a year.

Again, since patients are frequently driven to care by the depression presentation, patients with bipolar disorder are often misdiagnosed with unipolar major depression. 

Unipolar and bipolar disorder present with similar symptoms, but, as you know, are treated with different classes of medications. Making an accurate diagnosis can help ensure that patients receive the proper therapeutic approach.

[01:22] At every visit, I make sure to screen patients for depressive symptoms and then evaluate additional risk factors for bipolar disorder. This screening includes a comprehensive assessment of medical history.

Before we start our evaluation together, let’s briefly review the criteria for depressive episodes.

As you can see listed in the DSM-5 criteria, a major depressive episode is defined as five or more depressive symptoms, out of a total of 9 dimensions we check, these must include a depressed mood or decreased interest or pleasure. And I might add here that sometimes people don’t experience this as sadness, they may experience this as anhedonia or just feeling really numb. These symptoms must also be present for episodes of at least 2 weeks and be accompanied by a change in functioning. Other causes like substance use or other conditions should be ruled out. A complete evaluation includes assessing for all of the symptoms and specifications outlined in the DSM-5.

I find using clinical probes can really help break down the lengthy list of items that can feel tiresome to the patient. Rather than walking through a litany of symptoms, you can use these probes to initiate a more natural conversation.

[02:41] To start, We might ask the patient if they have been feeling depressed or down most of the day and then follow up to see how long they have felt this way.

I also ask if they have lost interest or pleasure in things they enjoy. This could include socializing, hobbies, or other activities. Another thing to check for is more social isolation. “I used to enjoy hanging out with my buddies, I don’t really do that anymore.” “I find I don’t enjoy hanging out with my kids as much as I used to.” And if it’s an older adult, if they’re not interested in seeing their grandchildren, that should pique your interest.

While these first two questions should help you get a better idea of what the patient has been going through, it’s also important to ask about physiological and cognitive changes.

We know that unipolar depression affects appetite and weight so it’s important to gauge if the patient’s appetite has changed or if they’ve noticed any weight changes. Weight changes are obviously the most objective view of what’s going on. Remember that in unipolar depression, appetite is a bimodal presentation: could be too much, could be too little, so it’s important for you to understand exactly what that change is. It becomes important when we talk about mania or hypomania.

You should also find out how much sleep they get and if they have experienced insomnia or hypersomnia. Sleeping too much or sleeping too little. Now, related to changes in sleep, fatigue is also a very common symptom, so find out if they frequently felt tired or run down.

[04:22] Now I’d like to stop a moment and take a cosmic highlighter to pay particular attention to this screening question because it’s an important one for helping you to distinguish if something is depressed, or hypomanic or manic. Remember, insomnia or hypersomnia is a bimodal presentation of depression, but mania has only a single mode of expression and that is reduced sleep, and increased energy.

So if a person tells you that they’re not getting much sleep but they feel wrecked during the day, they struggle to stay awake, they feel like they need naps, this tells you this is probably the insomnia pull of depression.

If they say to you they’re not sleeping and they don’t need it, they feel great, they’re sailing, and this is different from usual, that might lead you more in the direction of thinking about hypomania or a mixed episode.

On the other side of fatigue is restless behavior. Ask the patient if they have felt very fidgety or have had trouble sitting still. Since patients may not always recognize symptoms, you may ask if other people in their life have commented on their behavior.

Attention and concentration are often also affected, you may ask if it has been harder for them to focus or think things through. People may have trouble latching onto this question so I will ask them, “Can you start a project and finish it? Can you start an article and read it all they way through to the end? Can you start a TV show and watch it from the beginning all the way through? Or do you find yourself getting up and down a lot, or switching channels a lot?” These kinds of things can be helpful with a patient to determine whether they really are having a problem with attention and concentration.

[06:11] Now, before we leave this particular set of symptoms, the one about sleep, about restlessness, attention and concentration, one of the things I want to just put in your head here is you’re going to want to ask them at some point if they’ve ever been treated for depression.

If they’ve been treated with certain medications for depression that might cause, in a bipolar person, mania, if they tell you that when they’ve been treated with these medicines, suddenly they’re fidgety, or they can’t sleep, they’re restless, they’re moving around-- this may be a clue that you’re not looking at unipolar depression, you’re looking at bipolar depression. So just tuck that back there [in your head].

Let’s also talk about the depressive symptoms that bring with them a sense of guilt and self loathing. I will ask the patient, “Do you feel like you’re letting people down?” This is a good one that usually brings it out, even if they don’t recognize it as guilt or self-loathing. You may assess if the patient has been feeling this way for a long period of time, and the other question is “How bad is it?” At it’s worst, people may feel like a burden on others and maybe even feel like they don’t want to live anymore.

[07:33] So assess for those recurring thoughts of death or suicide, and sometimes a gentler approach may be “Do you feel like it would be better if you just weren’t here?”

Always take these seriously. Stop whatever you’re doing and probe carefully, and probe the history of this. The patient may need immediate treatment.

Remember that this is one of the most important symptoms that you’re looking for. If you’re thinking from a specifiers POV, even if they don’t have a lot of the other symptoms, suicidal ideation immediately changes the diagnosis from mild or moderate to severe. Pay close attention, probe carefully, and be sure to follow up if you let the patient go home.

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