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									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
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.
4. What have you thought about? Have you actually done anything to hurt
                                                        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
                                                                       thoughts become more
                                                                       prominent. Consult with mental
                                                                       health specialist as needed.

Current thoughts with plans                   High                     Emergency management by
                                                                       qualified expert

STABLE Toolkit. 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
            YES to Question #2
            ‘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. 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?
  [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
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.
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. Accessed June 2011.
               Mixtures of Manic and Depressed
                Symptoms are Commonly Seen
                Mixed Mania                   Dysphoric                  Depressive
                                                Mania                   Mixed States1

                        Full                      Mania
                       Mania                                                  2+ Mania
   Mania                                                                     Symptoms

                                             2+ Depressive
   MDE                                        Symptoms                           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
                                                                          ++         +
   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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