Evaluation of a Patient Presenting with Depression and Use of Screening Tools to Evaluate for Mania or Hypomania, Substance Abuse, and Suicide Risk J. Sloan Manning, MD Adjunct Associate Professor University of North Carolina–Chapel Hill Private Practice Greensboro, North Carolina Interview Questionnaires Patient Health Questionnaire 9 (PHQ-9) Name: Pauline Over the last 2 weeks, how often have you been bothered by any of the following problems? (use “” to indicate your answer) 1. Little interest or pleasure in doing things 0 1 2 3 2. Feeling down, depressed, or hopeless 0 1 2 3 3. Trouble falling or staying asleep, or sleeping too much 0 1 2 3 4. Feeling tired or having little energy 0 1 2 3 5. Poor appetite or overeating 0 1 2 3 6. Feeling bad about yourself–or that you are a failure or have let yourself or 0 1 2 3 your family down 7. Trouble concentrating on things such as reading the newspaper or watching 0 1 2 3 television 8. Moving or speaking so slowly that other people could have noticed. Or the 0 1 2 3 opposite–being so fidgety or restless that you have been moving around a lot more than usual 9. Thoughts that you would be better off dead, or of hurting yourself in some way 0 1 2 3 Total 21 10. If you checked off any problems, how difficult have these problems made it Not difficult at all for you to do your work, take care of things at home or get along with other Somewhat difficult people? Very difficult Extremely difficult Kroenke K, et al. J Gen Intern Med. 2001;16:606-613 Generalized Anxiety Disorder 7 (GAD-7) Name: Pauline Over the last 2 weeks, how often have you been bothered by any of the following problems? (use “” to indicate your answer) 1. Feeling nervous, anxious or on edge 0 1 2 3 2. Not being able to stop or control worrying 0 1 2 3 3. Worrying too much about different things 0 1 2 3 4. Trouble relaxing 0 1 2 3 5. Being so restless that it is hard to sit still 0 1 2 3 6. Becoming easily annoyed or irritable 0 1 2 3 7. Feeling afraid as if something awful might happen 0 1 2 3 Total 18 Spitzer R, et al. Arch Int Med. 2006;166:1092-1097. Evaluation of Suicide Risk for Clinicians Patient Name: Pauline Suicide Screening Questions When you make a diagnosis of unipolar of bipolar depression, suicide risk requires assessment. Ask the following progressive questions. If question 1 is negative and suspicion is low, you can skip the subsequent questions. Questions to assess thoughts of suicide YES NO 1. Have these symptoms/feelings (of depression) we’ve been talking about led you to think you might be better off dead? X 2. This past week, have you had any thoughts that life is not work living or that you’d be better off dead? X 3. What about thoughts about hurting or even killing yourself? If “Yes”, go to question 4. If “No”, stop. X 4. What have you thought about? Have you actually done anything to hurt yourself? 1. Suicide Risk as designated by the faculty and staff of South Texas Veterans Healthcare Systems and the University of Texas Health Risk factors for suicide1 (VERDICT UTHSCSA) Care Service Center. (VERDICT UTHSCSA) Hopelessness Prior suicide attempts Substance abuse X Caucasian race X Family history of suicide attempts Medical illness Male gender Family history of substance abuse Psychosis Advanced age Access to means Living alone Evaluation of Suicide Risk for Clinicians (cont) Assessment of Suicide Risk and Action Plan Description of Patient Symptoms Level of Risk Action No current thoughts; no major Continue follow-up visits and risk factors Low monitoring (Major Risks are BOLDED above) Current thoughts, but no plans Intermediate Assess suicide risk carefully at With or without risk factors each visit and Xcontract with patient to call you if suicide X thoughts become more prominent. Consult with mental health specialist as needed. Current thoughts with plans High Emergency management by qualified expert STABLE Toolkit. http://www.cqaimh.org/pdf/STABLE_toolkit.pdf. Accessed June 2011. Mood Disorder Questionnaire Patient Name: Pauline Mood Disorder Questionnaire (MDQ) Scoring A positive screen for possible bipolar disorder includes the following: YES to at least 7 of the 13 items in Question #1 AND YES to Question #2 AND ‘Moderate Problem’ or ‘Serious Problem’ for Question #3 The MDQ is for screening purposes only A comprehensive evaluation should follow a positive screen In primary care –Sensitivity: 58% –Specificity: 93% Hirschfeld RM, et al. Am J Psychiatry. 2000;157:1873-1875. Hirschfeld RM, et al. J Clin Psychiatry Prim Care Comp. 2002;4:9-11. Hirschfeld RM, et al. J Am Board Fam Pract. 2005;18:233-239. STABLE Toolkit. http://www.cqaimh.org/pdf/STABLE_toolkit.pdf. Accessed June 2011. WHO CIDI 3.0 Clinician-Administered Screening Tool Patient Name: Pauline Euphoria Stem Question 1. Some people have periods lasting several days when they feel much more excited and full of energy than usual. Their minds go too fast. They talk a lot. They are very restless or unable to sit still and they sometimes do things that are unusual for them, such as driving too fast or spending too much money. Have you ever had a period like this lasting several days or longer? Yes [If this question is endorsed, the next question (the irritability stem question) is skipped and the respondent goes directly to the Criterion B screening question] Irritability Stem Question 2. Have you ever had a period lasting several days or longer when most of the time you were so irritable or grouchy that you started arguments, shouted at people or hit people? Criterion B Screening Question 3. People who have episodes like this often have changes in their thinking and behavior at the same time, like being more talkative, needing very little sleep, being very restless, going on buying sprees, and behaving in many ways they would normally think inappropriate. Did you ever have any of these changes during your episodes of being excited and full of energy or very irritable or grouchy? Yes Kessler R, et al. J Affect Disord. 2006;96:259-269. WHO CIDI 3.0 Bipolar Screening Scales Scoring The complete set of 12 Questions takes approximately three minutes to complete 2 Stem questions: Questions 1 & 2 Respondents who fail to endorse either of these first two questions are skipped out of the remainder of the question series 1 Criterion B Screening Question: Question 3 • Respondents who fail to endorse this question after endorsing one of the first two stem questions (above) are skipped out of the remainder of the question series • Respondents who do endorse this question are then administered the 9 additional symptom questions Note: In a general population sample, it can be expected that as many as 90% of the sample will skip out by the end of this third question Kessler R, et al. J Affect Disord. 2006;96:259-269.. WHO CIDI 3.0 Clinician-Administered Screening Tool (cont) Patient Name: Pauline Criterion B Symptom Questions Think of an episode when you had the largest number of changes like these at the same time. During that episode, which of the following changes did you experience? 1. Were you so irritable that you either started arguments, shouted at people, or hit people? No The first symptom question is asked only if the euphoria stem question (#1 above) is endorsed. 2. Did you become so restless or fidgety that you paced up and down or couldn’t stand still? Yes 3. Did you do anything else that wasn’t usual for you – like talking about things you would normally keep private, or acting in ways that you would usually find embarrassing? Yes 4. Did you try to do things that were impossible to do, like taking on large amounts or work? Yes 5. Did you constantly keep changing your plans or activities? Yes 6. Did you find it hard to keep you mind on what you were doing? Yes 7. Did your thoughts seem to jump from one thing to another or race through your head so fast you couldn’t keep track of them? Yes 8. Did you sleep far less than usual and still not get tired or sleepy? Yes 9. Did you spend so much more money than usual that it caused you to have financial trouble?Yes Kessler R, et al. J Affect Disord. 2006;96:259-269.. WHO CIDI 3.0 Bipolar Screening Scales Scoring (cont) 9 Criterion B Symptom Questions • Each of the 9 symptom questions are administered Note: The first question in this group is asked only if the first Stem Question is endorsed. If this scenario occurs, then only the 8 remaining symptom questions would be administered. Very high risk (80% or more) 9 questions with positive endorsement High risk (50-79%) 7-8 questions with positive endorsement Moderate risk (25-49%) 6 questions with positive endorsement Low risk (5-24%) 5 questions with positive endorsement Very low risk (less than 5%) 0-4 questions with positive endorsement Diagnosis based on the screening scales have excellent concordance with diagnoses based on the full WHO Composite International Diagnostic Interview (CIDI 3.0). CIDI Diagnoses, in turn, have excellent concordance with clinical diagnoses based on blinded SCID clinical appraisal interviews. AUDIT-C Name: Pauline AUDIT-C Questionnaire 1. How often do you have a drink containing alcohol? a. Never b. Monthly or less c. 2-4 times a month d. 2-3 times a week e. 4 or more times a week 2. How many standard drinks containing alcohol do you have on a typical day? a. 1 or 2 b. 3 or 4 c. 5 or 6 d. 7 to 9 e. 10 or more 3. How often do you have six or more drinks on one occasion? a. Never b. Less than monthly c. Monthly d. Weekly e. Daily or almost daily AUDIT-C Scoring Each question is scored according to the following point allotment: a: 0 points b: 1 point c: 2 points d: 3 points e: 4 points For men, a score of ≥ 4 is considered positive; optimal for identifying heavy drinking or active alcohol use disorders For women, a score of ≥ 3 is considered positive When the points are from Question #1 only, and the responses for Questions #2 and 3 are ‘a’ (point value 0), the individual’s drinking behavior is considered below recommended limits A higher score on the AUDIT-C is generally associated with greater likelihood that drinking is impacting the patient’s safety Bush K, et al. Arch Int Med. 1998;158(16):1789-1795. STABLE Toolkit. http://www.cqaimh.org/pdf/STABLE_toolkit.pdf. Accessed June 2011. Mixtures of Manic and Depressed Symptoms are Commonly Seen Mixed Mania Dysphoric Depressive Mania Mixed States1 Full Full Mania Mania 2+ Mania Mania Symptoms 2+ Depressive MDE Symptoms Full Full MDE MDE MDE = major depressive episode Agitated depressions? 2,3 1. Benazzi F. Psychiatry Res. 2004;127:247-257. 2. Maj M, et al. Am J Psychiatry. 2003;160:2134-2140. 3. Akiskal HS, et al. J Affect Disord. 2005;85:245-258. Factors Distinguishing Bipolar and Unipolar Depression Diagnostic Variable Bipolar Unipolar Spontaneous hypomania +++ - Atypical depression + +/- Premorbid affective temperament, particularly hyperthymic or ++ - cyclothymic temperament Mood lability ++ - Increased mental/physical energy during depressions ++ - Family history of bipolar disorder or response to lithium ++ - Loaded pedigree for the disorder ++ +/- Marital discord, frequent change in line of work or frequent ++ + relocation High frequency of episodes ++ + Early onset (age < 26 yrs) of mood disturbance ++ + Treatment-emergent hypomania/mania/mixed states +++ - > 2 Antidepressant failures ++ + Manning JS. Prim Care Companion J Clin Psychiatry. 2010;12(S1):17-22. Differential Diagnosis: Bipolar Disorder or Unipolar Depression? 1. Family History Higher rates of psychiatric illness Positive for bipolar disorder 5. Mania Symptoms Distractibility, decreased 2. Course of Illness need for sleep, grandiosity, Key Age of first mood disturbance < age 25 racing thoughts, increased activities, pressured speech, Elements Greater severity of episodes persistent irritable mood, Higher frequency of episodes thoughtlessness Marked seasonality 4. Associated Features 3. Treatment Response Unevenness in intimate relationships Multiple treatment failures Frequent career changes Non-response or erratic Substance use disorders response to antidepressants Adapted from the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Text Revision. Washington, DC: American Psychiatric Association; 2000:345-428. Critical Take Away In its most common expression, bipolar disorder is a depressive illness. Manic or hypomanic episodes may be discrete and relatively pure, but are often mixed with depressed mood.
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