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What Does Accountable Care Mean for Early Career Psychiatrists?

We are in the midst of a shift in the framework of health care delivery in America. Currently, most health care professionals in America are reimbursed for care provided, whether that service is for acute illness or preventive care, and reimbursement comes from the patient’s pocket, the insurance company, or the government. This model incentivizes health care providers to perform high-cost procedures and care for acute illness rather than provide preventive care and care for chronic illness.

A new model is emerging in the form of the Accountable Care Organization (ACO) and is often described as “population health care.” ACOs care for a population of patients with a fixed amount of reimbursement per member for a fixed amount of time. In an editorial in the October 30, 2014, issue of the New England Journal of Medicine, Dr Lawrence Casalino described the central goal of the ACO program as improving the value of care provided, defined by improved quality at a reduced cost. Dr Casalino also elaborated on potential pitfalls that may hinder development of the ACO movement and skewed motives that may hamper increase in true value of care provided. In the same issue, Song et al and McWilliams et al described the experiences of some of the pioneering ACOs, and, broadly speaking, these studies showed an improvement in quality and reduction in cost.

What will this movement mean for early career psychiatrists? Along with other fields, we will increasingly be required to demonstrate the quality of care that we provide. While providing high-quality care has always been paramount in medicine, how do we demonstrate that we are doing this? Using measurement-based care systems and demonstrating adherence to treatment guidelines are two ways to systematically measure quality of care in psychiatry.

I recommend that early career psychiatrists familiarize themselves with outcomes measures that can be implemented in routine clinical care. In the clinic, we ask our patients to tell us, for example, about their mood over the past 3 months. However mood, like pain, is difficult to remember accurately. When I introduce outcomes measures to my patients, I say that this measure will help both of us recall the specifics of symptoms at certain time points in the course of treatment, which will give us data to use in individualized treatment decisions.

At Penn State Psychiatry, we are implementing a systematic program of diagnostic and outcomes measurements to enhance clinical care and quality programs. Health care organizations will be increasingly interested in these kinds of data, as objective outcomes data can be collected in the aggregate to show outcomes by treatment provider or treatment setting.

Measurement-based care in psychiatry has been recommended by experts and called for in APA Practice Guidelines. Familiarity with published treatment guidelines issued through professional organizations or government health care systems abroad (eg, American Psychiatric Association, British Association for Psychopharmacology, Canadian Network for Mood and Anxiety Treatments, National Institute for Health and Clinical Excellence) is crucial for understanding the standard of care and for measuring one’s own treatment efficacy. Health care is changing, and being able to demonstrate quality of care will be increasingly important in psychiatry as in all of medicine.

Financial disclosure: Dr Saunders is a consultant for Profiles in Knowledge.

Patient Falls and Psychiatric Medications

Patient falls, some of which are fatal, were the subject of a sentinel event alert by The Joint Commission on Accreditation of Healthcare Organizations in 2000, and fall reduction was a 2014 Joint Commission national patient safety goal. In 2014, The Joint Commission’s Center for Transforming Healthcare reported that a pilot project to prevent falls was able to reduce both falls and injuries from falls at the 7 participating organizations.

Behavioral health facilities have not been rigorously studied, but a 2009 study in Pennsylvania found that falls in psychiatric hospitals were more frequent than in medical-surgical facilities (21.7% vs 15.4%), with patient harm as a result of falls also greater in psychiatric facilities (9.6% vs 3.7%). The association of medications with falls was significantly greater in behavioral health facilities than in non–behavioral health hospitals (70.3% vs 57.6%).

Behavioral health units have a number of risk factors for falls. Many of the patients are taking multiple psychiatric as well as medical medications that can cause sedation and orthostatic hypotension. Some of the patients may also be confused or agitated, while others may have gait impairment or extrapyramidal symptoms. Detoxification of alcohol-, opioid-, or benzodiazepine-dependent patients presents a fall risk, even in younger patients, because patients may be in a delirium from the intoxicating substance and/or be cognitively impaired from the medications commonly used in detox protocols. A study of psychiatric inpatients found that risk factors for falls included a diagnosis of depression and confusion or disorientation. The majority of falls occurred when patients were attempting to get out of bed, walk to the bathroom at night, or move from a sitting to standing position.

A retrospective analysis of 148 psychiatric inpatients found that those who fell were more likely to have an acute medical condition, complain of more physical symptoms, and be prescribed more medications than those who didn’t fall. Fallers were significantly more likely than nonfallers to be taking antihypertensive medications (19% vs 3%) and clonazepam (42% vs 18%). Benzodiazepines generally appear to add to fall risk. In a study of nursing home residents, patients taking benzodiazepines experienced a 44% greater rate of falls than nonusers. Additionally, imidazopyridine sleep aids (eg, zolpidem) have been associated with confusion, daytime somnolence, and dizziness in older inpatients, and falls may result. Antidepressants and antipsychotics also may increase the risk of falls via drowsiness, imbalance, confusion, orthostatic hypotension, and involuntary muscle contraction.

The Centers for Medicare & Medicaid Services has taken a strong stand on antipsychotic medication by setting a goal to reduce the use of these medications in nursing homes by 30% from 2012 to the end of 2016, with exclusion only for the diagnoses of schizophrenia, Tourette’s syndrome, and Huntington’s disease. More studies should be done to look at which antipsychotics and doses are most risky for falls and if any may be deemed as less risky to use. One nursing home study found that, while falls were more common among residents taking high doses of quetiapine (> 150 mg/d) or risperidone (> 2 mg/d) compared with residents not taking an antipsychotic, low doses of quetiapine or risperidone and any dose of olanzapine were not associated with a higher risk of falls.

Medical professionals, especially psychiatrists, need to become more educated, aware, and involved in fall prevention. The Institute for Clinical Systems Improvement protocol summary to prevent falls in inpatients recommends that a complete falls assessment should be made by the physician, nurse, and pharmacist. Unnecessary medications need to be discontinued. Medications with the side effects of sedation, confusion, and orthostatic hypotension need to be evaluated and altered appropriately.

Financial disclosure: Dr King had no relevant personal financial relationships to report.

How Have Views on Nutrition and Mental Health Changed?

Human knowledge of the relationship between nutrition and mental function probably goes back in time for many thousands of years, but it has been documented for “only” ~2,700 years. Join us now for a fun ramble through history.

When was the first report of a clinical trial on the impact of nutrition on mental/cognitive health? It’s in the Bible, in the first part of the Book of Daniel. At the beginning of the Babylonian Exile that lasted about 50 years until ~538 BCE, King Nebuchadnezzar pillaged Jerusalem and took captives back to Babylon. Nebuchadnezzar wanted the captured youths, who would train for 3 years to serve in his palace, to eat the same food as the royal family. One captive, Daniel, did not like the idea of “defiling” his body with a diet that seems to have been rich in meat and alcohol. So Daniel proposed a 10-day trial in which he and 3 friends would be given only legumes and water, and then the king could compare the 4 of them with those eating the royal diet. The result, variously translated, was that after 10 days, “in all matters of wisdom and understanding, … he found them ten times better” than the others. In other words, diet affected brain function! (Side note: Some people now follow a “Daniel diet.”)

What was the view of the ancient Greeks toward food and nutrition? Is there any quotation more frequently attributed to Hippocrates than this one? “Let food be thy medicine, and medicine be thy food.”

How did people in the modern era view nutrition and mental health prior to the explosion of pharmaceuticals in the mid-20th century? Mrs Beeton’s Book of Household Management, first published in 1861, provided a guide to running a household in Victorian Britain. This 1,112-page tome mostly contains recipes but also has sections on how to manage children, the servants, and properties, as well as a section dedicated to how to keep well—a large portion of which discusses the role of food. A section devoted to “invalid” cookery shows the wisdom of the time about the importance of diet:

Diet can often cure where drugs are useless or worse. Diet is always harmless where drugs are usually dangerous. Every year diet plays a larger part in the skilled treatment of disease. And yet we often see unskilled women, who would hesitate before changing their children’s diet from roast meat and milk puddings, more than before pouring down their throats all manner of powerful medicines. For the majority of common ailments, some slight change of diet is by far the best remedy.

For the most part, Mrs Beeton was talking about the treatment of physical ailments; however, she also appreciated the role that food played in the expression of psychological symptoms: “If we consider the amount of ill-temper, despondency, and general unhappiness which arises from want of proper digestion and assimilation of our food, it seems obviously well worth while to put forth every effort, and undergo any sacrifice, for the purpose of avoiding indigestion, with its resulting bodily ills.”

Are there North American examples of Mrs Beeton-type wisdom before the current age of pharmaceuticals? We found a major reference used throughout the American west and the prairie provinces of Canada in the early 20th century. The 1910 book The People’s Home Library was a source of in-depth, practical knowledge, especially for those living far from health care for themselves or their livestock. In three volumes, The People’s Home Library taught you how to cook, treat various ailments, make soap, increase your supply of breast milk, build a house, care for your livestock, and much more. One volume is entirely recipes (the other two are about medical and livestock issues). When we found a copy in rural Alberta, we found text that said, “The number one cause of acquired insanity is imperfect nutrition.” Food was always known to be important, including for mental health.

Has processing of food resulted in a poorer diet? Perhaps some of us heard our grandparents talk about how they ate prior to World War II, before processed food became widely available. Some will recall their attitude that food processing (in particular, preservation by canning and freezing) improved our nutrition enormously. It enabled the population-at-large to eat produce year round that otherwise was available only in the summer. But the early days of processing that broadened accessibility of fruits and veggies gradually gave way to packaged food. In a future post, we will review some of the research comparing the mental health of people who eat mostly processed food to that of people who eat a traditional diet.

So, our ancestors knew that nutrition is a big part of the mental health picture. We believe that the rise of the pharmaceutical era eclipsed the rich historical knowledge that our ancestors had about the importance of food for maintaining good mental health.

This blog entry is adapted from a previous entry that can be found athttp://www.madinamerica.com/2013/04/study-the-past-if-you-would-define-the-future-confucius/.

Financial disclosure: Drs Kaplan and Rucklidge had no relevant personal financial relationships to report, and no company has ever funded any of their studies.

Is It My Childhood, Adulthood, or Am I Just Crazy Enough to Be a Psychiatrist?

Dr Iskandar: “You must’ve had a bad childhood” is what my internal medicine attending physician said when I told him during medical school that I was going into psychiatry. Years later, when I decided to survey primary care residents in two teaching hospitals about their perspectives on mental health, I couldn’t resist asking a question about what they think of us. The question was, what percentage of mental health care professionals (MHPs) do you think has mental health problems? The answer choices were 25%, 50%, 75%, and over 75%.

Of course, my selfish reason was to know what they really think of me when I work or sit at lunch with them daily. Unfortunately, the survey revealed a positive correlation between primary care residents’ advancing training level and their growing belief that MHPs have mental health problems. While 60% of first-year and 70% of second-year residents reported a belief that 25% and 50% of MHPs, respectively, have mental health problems, 80% of third-year residents reported a belief that more than 75% of MHPs have mental health problems.

In denial, I told myself that these results are not statistically significant, and maybe they do not represent our colleagues’ true perceptions of us. But, if true, how do the perceptions of primary care residents form and grow with time?

I decided to ask Dr Eric Vance, my mentor and a coauthor of the study, about his experiences dealing with the perceptions of others about his career choice.

Dr Vance: In my experience, the survey confirms the perceptions of many people outside of our profession—that those who become MHPs end up there due to having their own mental health problems. As for me, I recall choosing the field due to thinking that the brain was the most interesting organ in the body (and meeting a couple of cool psychiatrists in med school). Of course that didn’t keep my father from asking why I didn’t choose to be a “real doctor.” My father passed away before he repaired all the damage caused by his own narcissism, but, by entering psychiatry, I’ve been able to gain enough insight to control my own. Perhaps if I hadn’t become an MHP, my unexamined narcissism would’ve served me in the role of a ruthless businessman, or a tyrannical surgeon terrorizing residents and medical students. I’ve also heard the common perception that psychiatrists as a group are “a bunch of oddballs.” I acknowledge that I’ve met many colorful MHPs over the years, but do we really have more mental disorders than the pathologist with Asperger’s, the depressed internist with no bedside manners, or the addicted anesthesiologist? I’m not sure I went into the field to “figure out my own problems,” but I think maybe it has helped a bit. In any case, most people eventually realize that very few of us can solve our own problems, and the help of another person is often needed to guide us. That person is often an MHP.

Dr Iskandar: Then, should we accept the perception or fight it?

Financial disclosure: Drs Iskandar and Vance had no relevant personal financial relationships to report.

See also “Why Become a Psychiatrist? The Id Speaks” by Aditya Joshi, MD.

How Does Nutrition Affect the Brain?

The two of us are so pleased to be invited to blog on the role of nutrition in mental health. As research psychologists (and Julia is also a clinical psychologist) who have spent years studying nutrition in relation to mental health, behavior, and brain development, we know how beneficial good nutrition can be for some people with mental health problems. But we also know that many people reading this blog are unaware of the tremendous scientific inroads made on this topic over the last decade. Julia is faced with this issue when teaching clinical psychology students, many of whom enter the field believing that the only ways to influence psychological symptoms are talk therapies and psychotropics. They are typically genuinely surprised that our brains can be influenced by what we eat.

Even some people who are very knowledgeable about the importance of good nutrition and other lifestyle factors for physical health are not yet aware that these lifestyle variables also significantly influence brain health. Here is why we find this disconnect so strange: THE BRAIN IS PART OF THE BODY.

It seems inane even to write that statement, especially to this audience, but many of us in the health field refer to “mind-body connections” and “mind-body medicine,” perpetuating the myth of separation. We even separate mental health (“the mind”) from neurological function (“the brain”). But brain health, mental health, and bodily health are interconnected. Nutrients are needed for all cellular growth and metabolism, and the brain places large demands on energy metabolism. Here are two bits of information that we find somewhat amazing and that illustrate this fact:

  1. The brain is approximately 2% of our whole body weight, but it consumes 20% of our metabolism. In other words, the brain is constantly and disproportionately demanding nutrients.
  2. Every single minute, almost a quart of blood passes through your brain. Why? That quart of blood is bringing nutrients and oxygen (and other metabolic products) to every single nook and cranny in your cranium. So, we can ask ourselves—what have we eaten in the last day or so? Those are the chemicals bathing our brains.

Related topics to explore in our future blog posts include the following:

  • The history of nutrition and mental health, going back ~2700 years
  • How mental health and nutrition were viewed prior to the development of psychotropic medications in the 1950s and '60s
  • The scope of single-nutrient treatments from 1920 to the present
  • The emergence of broad-spectrum nutrient treatments in the 21st century
  • Epidemiologic data on the relationship between nutrition and mental function
  • The 2013 development of the field of ‘nutritional psychiatry’ and the new scientific group ISNPR (International Society for Nutritional Psychiatry Research)
  • Nutritional treatment options for various mental disorders (watch Julia’s recent TEDx talk)
  • The role of microbiota in mental health
  • The psychological effects of starvation: what are the lessons from the Minnesota Starvation Experiment and the Dutch Hunger Winter famine?
  • How does nutrition research in the past decade lead to a new conceptualization of mental illness?
  • Whether supplementation is necessary for the “normal” population
  • New publications that influence public policy
  • The challenges of studying and publishing on dietary influences on mental health
  • The importance of increased nutrient intake after natural disasters
  • And so much more: What do we know about nutrients and addictions? What is the mechanism by which nutrition influences mental health? What does nutrition have to do with inflammation?

We look forward to discussing these topics with you.

This blog entry is adapted from a previous entry that can be found at http://www.madinamerica.com/2013/04/nutrition-and-mental-health/.

Financial disclosure: Drs Kaplan and Rucklidge had no relevant personal financial relationships to report, and no company has ever funded any of their studies.

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Aggressive Inpatients in a Community General Hospital

Patients who are aggressive and present with characteristics and behaviors associated with a significant risk for physical violence are not uncommon in the acute inpatient behavioral health units of general hospitals.Treating the aggressive patient challenges clinicians to safely, expeditiously, and effectively manage the needs of both the aggressive patient and the unit’s entire patient population.

Several factors contribute to the admission of aggressive patients to general hospitals’ psychiatric units, including the closing of state hospitals; insufficient housing for mentally ill, intellectually disabled, and addicted individuals; the recurrent problem of community treatment unsuccessfully managing aggressive patients; and controversy regarding if or when these patients’ actions necessitate incarceration. And, although staff may hope this trend of admitting aggressive patients abates, studies have stated that this population merely reflects society and will, therefore, continue to be present.

Research has shown that acts of aggression are most likely to occur within the first or second week of hospitalization. Predictors have frequently been utilized to identify which patients are most at risk for aggressive behavior while hospitalized and are typically grouped by categories such as demographics (eg, age, sex, history of violence, psychosocial factors), clinical characteristics (eg, diagnosis, substance use, personality disorders, symptoms, severity of illness), contextual factors (eg, unit environment), and staff contributors (eg, communication skills, aggression training).

The results of our prospective study on aggressive patients cited younger males with a history of previous violence, past psychiatric admissions, and severe symptoms of agitation (defined as excessive, purposeless motor activity) as being more at risk for aggressive behavior during acute psychiatric hospitalization than other patients. Additionally, our results suggested that positive psychotic symptoms, a diagnosis of bipolar disorder, and substance use also contributed to aggressive behavior. We also identified a relationship between the participants’ severity of illness and level of aggressiveness.

In study participants, paranoia was the symptom most successfully reduced/treated by medication. The medications we used for our study participants seemed efficacious, as significant improvements were seen in psychometric scale scores (CGI-S and MOAS) from baseline to last visit; however, the overall positive effects of the therapeutic inpatient environment and routine must also be considered as important contributors to patient improvement.

Our study showed high rehospitalization rates for aggressive patients, which suggests that patients with aggression issues are difficult to treat and difficult to keep in compliance with treatment on an outpatient basis. This finding highlights the need to strengthen community mental health centers through an increase in public-private partnerships.

Financial disclosure: Dr Mittal is a consultant for Janssen, Otsuka, and Teva. Ms Nourse had no relevant personal financial relationships to report.​

Rumors in Personal Life

In a recent article in The Primary Care Companion, my colleagues and I discussed the potentially toxic impact of rumors on the internal functioning of a psychiatric department. However, rumors also have the potential of heavily impacting people’s lives, which carries clinical significance for the practicing psychiatrist.

I have encountered clinical situations with patients who were seeking help for trauma resulting from rumors propagated via electronic media. One characteristic of this particular way of spreading rumors is the fact that, due to the anonymous nature of the Internet, these rumors tend to generate in victims a sense of severe helplessness and loss of control.

Case Vignette

Ms A was a 40-year-old, married executive secretary, with a long career in the corporate world. She found herself in the midst of a family dispute with her 4 siblings over their father’s large estate. Over the period of a year, a relatively close-knit family became involved in contentious litigation over their father’s estate. At that point, a barrage of anonymous, calumnious statements about Ms A appeared on the Internet: a criminal history including prostitution, theft, drug possession, and tax evasion, as well as a teenage pregnancy and abortion. None of these allegations had any basis in truth, and thus Ms A confidently dismissed and ignored them. However, as they were posted on the Internet in association with her correct name and identity, they became part of the information readily retrievable to anyone typing her name into a search engine. What followed seemed surreal for Ms A. As she related in session, her world gradually became shattered over a period of 6 to 8 months. People at work started making innuendos. Then, her supervisor called her in to discuss the claims found on the Internet, apparently having been notified by coworkers. There were concerns about the corporate image. In spite of the fact that Ms A denied all of the allegations, a cloud of doubt about her past continued. This was unjustified given the fact that criminal activities and personal histories can be confirmed and denied through background checks. Friends, acquaintances, and coworkers seemed to slip into a state of ambiguity, despite having no proof for any of these allegations. This ambiguity created distance between Ms A and her entire support system. In time, Ms A became isolated. Her employer did not take any action. The entire matter was treated with silence, which may have contributed to the rumor effect.

When Ms A first visited my office, she presented with symptoms of PTSD, eg, intrusive thoughts about the rumors and the related consequences, nightmares, guardedness, and heightened suspicion. She developed depression and a chronic sense of anhedonia about everyday life activities, work, and previously enjoyed leisure activities. Treatment with psychotherapy included a restructuring of her trauma-related suspicious cognitions. In addition, supportive and dynamic techniques were utilized to create a new forum of reality, away from the cloud of rumors in which she was now operating. It was particularly helpful to tap into the resource of a supportive marriage. Therefore, occasional conjoint sessions were scheduled. In addition, Ms A showed a positive response to treatment with SSRIs, which decreased the rumination and obsessive thinking. Treatment has been maintained long-term. Today, a year later, Ms A has persistent guardedness about coworkers and friends, but her nightmares and depression have remitted. She has not maintained contact with any of her siblings, as it was suspected that the younger brother had initiated the rumors.

Discussion

The above case illustrates the malignancy of rumors propagated over the Internet. The ambiguous nature of rumors makes them a pathogen that can produce particularly prolonged effects. Thus, the combination of the power of Internet information and the human tendency to believe legends and rumors, when misused, will shatter people’s lives. The Internet provides no sure privacy safeguards. Treatment for patients in these situations has to be focused on rebuilding their confidence, addressing their faulty cognition that everyone privy to the rumors will believe them, and encouraging them to move to a different stage in life. There is certainly evil and insecurity in the world. However, one of the long-term goals of treatment should be to penetrate the defenses of posttraumatic thinking and re-expand our patients’ vision to internalize the experience of good and beauty.

As a final note, we often underestimate the value of long-term maintenance treatment in enhancing functionality after severe trauma, as opposed to the limited treatment needed to achieve remission in the case of an episodic psychiatric disorder. Most clinical studies, especially in psychopharmacology, are short-term, lasting only until first remission, and often we have no information about outcome 5 or 10 years later. For some patients, recurrence is the rule; for others, the exception. Treating patients with trauma sometimes requires stepping aside from the norms set by the many treatment studies with limited timeframes.

Financial disclosure: Dr Novac had no relevant personal financial relationships to report.

Another Day, Another E-Mail: Looking at What Lies Beneath

Almost every day, I receive an e-mail from a desperate mother. She is writing because she suspects that her daughter has ADHD and is looking for help. In some instances, the girl is young, the symptoms are clear cut and agreed upon by parents and teachers, and mom is just looking for a referral. But, in too many cases, the girl has already been seen by a mental health professional and the diagnosis of ADHD has been missed or mom fears her daughter is misdiagnosed. The following e-mail was received recently and is unfortunately quite typical. (All identifiers have been removed or changed to maintain privacy.)

Dear Dr. Quinn,

My daughter is a sophomore (freshman, senior, etc) at XXXX High School (or College), where she is struggling. She was told by a school counselor (psychologist, psychiatrist) that she is most likely bipolar. She was recently prescribed medication for this diagnosis by a psychiatrist. However, we see her as ADHD: she can be moody and sensitive but has never been really depressed; she starts new projects with enthusiasm, but the follow-through is lacking. She can spend impulsively, and deadlines are always a challenge for her unless they relate to a high-interest activity. She is invariably good at what she does but is sensitive to perceived criticism. She is very bright but has a history of academic underachievement since middle school.

I realize you can't diagnose her on the basis of this brief description, but I am concerned that she has been misdiagnosed. Her moods are always in response to life events: the scale and severity may seem atypical, but there is always a trigger. Can you refer me to someone who is informed and aware of the presenting symptoms and prevailing wisdom regarding treatment of ADHD (without hyperactivity)?

Please help!
Concerned Mom
p.s. My daughter runs track, which may be a mitigating factor for her not demonstrating hyperactivity.

Does this girl have bipolar disorder, ADHD, or both? Unless you entertain the diagnosis of ADHD, you’re going to miss it. Let’s look at the odds for her having a diagnosis of ADHD versus bipolar disorder or both. First, ADHD is about twice as common as bipolar disorder in both children and adults.1,2 Bipolar disorder affects only a fraction of children and adolescents with ADHD; however, among those with bipolar disorder, the likelihood of having comorbid ADHD is high.1 Several research studies have demonstrated that the earlier the mood swings of bipolar disorder start, the more likely coexisting ADHD is; 40% to 90% of children and adolescents who are diagnosed with bipolar disorder also have ADHD symptoms.3-5 Among children with ADHD, however, only 23% have bipolar disorder.6

In adults, the pattern of comorbidity is the opposite. Studies7,8 estimate that 10% to 21% of adults with bipolar disorder also have ADHD diagnosed in adulthood, while 47% of adults with ADHD have bipolar disorder. Incidence of coexisting bipolar disorder varies by ADHD presentation in adults; one study9 found that 23% of those with combined type, 6% of those with inattentive type, and 38% of those with hyperactive type ADHD also had bipolar disorder.

Second, ADHD and bipolar disorder share several features, including mood fluctuations, increased energy levels, hypertalkativeness, impulsivity, “racing thoughts,” irritability, and sleep disturbances.1,10 In addition, they both have a chronic course with life-long impairment, as well as a strong genetic component. However, ADHD and bipolar disorder can be distinguished on the basis of several differences. These include age at onset, persistence of symptoms, and qualities of the mood fluctuations, including duration, stability, and whether they are in response to real stimuli in the environment.

Third, ADHD symptoms are present throughout the lifespan. For a diagnosis, symptoms must be present (although not necessarily impairing) by age 12 years.10 Conversely, bipolar disorder can be present in young children, but such an occurrence is rare. Thus, symptoms that begin prior to puberty are more often due to ADHD. In addition, symptoms of ADHD are always present while bipolar disorder is episodic, with normal moods occurring between episodes.

Women and girls with ADHD often have strong emotional reactions to the events in their lives. This clear triggering of mood shifts by real events distinguishes ADHD from bipolar mood shifts that come and go unrelated to life events.10 Rapid ADHD mood swings are usually the result of stimuli in the environment that can shift rapidly, sometimes within minutes. However, the mood swings of bipolar disorder often occur over days or weeks even in the most “rapid cyclers.” A rapid cycling bipolar disorder is defined as one in which an individual experiences at least 4 shifts of mood over a year. Many females with ADHD have that many mood shifts in a single day!

When ADHD and bipolar disorder occur together, both must be properly diagnosed and treated in order for these girls and women to improve. Great caution must be taken to make sure you don’t miss ADHD when making a diagnosis of bipolar disorder or misdiagnose ADHD as bipolar disorder in a discouraged (or depressed) female teen or young adult. Looking at what lies beneath often will give you the answer and keep my inbox clear!

Financial disclosure: Dr Quinn is a member of the speakers board for Shire.

References

1. Galanter CA, Liebenluft E. Frontiers between attention deficit hyperactivity disorder and bipolar disorder. Child Adolesc Psychiatr Clin N Am. 2008;17(2):325–346. PubMed

2. Kessler RC, Berglund P, Demler O, et al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):593–602. PubMed

3. Sachs GS, Baldassano CF, Truman CJ, et al. Comorbidity of attention deficit hyperactivity disorder with early- and late-onset bipolar disorder. Am J Psychiatry. 2000;157(3):466–468. PubMed

4. Masi G, Perugi G, Toni C, et al. Attention-deficit hyperactivity disorder–bipolar comorbidity in children and adolescents. Bipolar Disord. 2006;8(4):373–381. PubMed

5. Joshi G, Wilens T. Comorbidity in pediatric bipolar disorder. Child Adolesc Psychiatr Clin N Am. 2009;18(2):291–319. PubMed

6. Beiderman J, Faraone SV, Mick E, et al. Attention-deficit hyperactivity disorder and juvenile mania: an overlooked comorbidity? J Am Acad Child Adolesc Psychiatry. 1996;35(8):997–1008. PubMed

7. Nierenberg AA, Miyahara S, Spencer T, et al. Clinical and diagnostic implications of lifetime attention-deficit/hyperactivity disorder comorbidity in adults with bipolar disorder: data from the first 1000 STEP-BD participants. Biol Psychiatry. 2005;57(11):1467–1473. PubMed

8. Wingo AP, Ghaemi SN. A systematic review of rates and diagnostic validity of comorbid adult attention-deficit/hyperactivity disorder and bipolar disorder. J Clin Psychiatry. 2007 Nov;68(11):1776-1784. Full Text

9. Wilens TE, Biederman J, Faraone SV, et al. Presenting ADHD symptoms, subtypes, and comorbid disorders in clinically referred adults with ADHD. J Clin Psychiatry. 2009;70(11):1557–1562. Full Text

10. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, DC: American Psychiatric Association; 2013.

Rapid Cycling: Still a “Foggy” Situation

Although cycling acceleration was portrayed long ago, when Bleuler described a 50-hour cycle in a patient suffering from a mood disorder, the limited existing data do not allow clear conclusions regarding the clinical phenomenology, prevalence, and clinical correlates associated with rapid cycling.1

Additionally, misconceptions exist regarding overlap between this clinical variable and other clinical phenotypes. For example, patients with rapid cycling bipolar disorder are often misdiagnosed as suffering from a mixed episode. The only clinical situation, however, in which a manic or a hypomanic episode coexists in the same period of time as a full-blown major depressive one (as required by the modern classification systems) is within the nosological entity recognized as ultra-rapid cycling.2

Some fundamental questions about rapid cycling remain more or less unanswered. Is it a frequent clinical situation? How is it triggered? Is there a recognized relationship with environmental factors? Is there a specific biological substrate? Is it a real subtype with temporal stability or is it a course specifier?

To answer some of these questions, my colleagues and I performed a systematic review3 of the available data regarding rapid cycling, which was recently published in The Journal of Clinical Psychiatry.

We found some interesting answers. First of all, it seems that rapid cycling is a rather frequent clinical condition. Although the prevalence rates vary widely, we calculated that the mean weighted annual prevalence rate is 18.10%, while the lifetime prevalence rate is estimated to be 31.48%.3 Moreover, prevalence seems dissimilar among females and males, and a previous meta-analysis by Kupka and colleagues4 reported a close association between female gender and rapid cycling. Regarding age at onset, it seems that bipolar illness begins earlier among patients with rapid cycling (before 17 years) than among those without.

Does rapid cycling have a specific biological substrate? Do environmental triggers exist? A relationship between rapid cycling and hypothyroidism has been described (but not unanimously accepted) as a part of a more complex inter-correlation that also is associated with female gender and lithium treatment.5 Furthermore, the etiological relationship between the use of antidepressants and rapid cycling is less clear than once was thought, as it seems that only a fraction of patients will develop this course after the use of antidepressants.3 Beyond triggering factors, the findings from the field of genetics were not convincing. There is not an increased familial load for rapid cycling bipolar disorder.4 Furthermore, despite the existence of genetic studies, their limited number and the lack of replication is still a problem. Overall, the existing data are insufficient and cannot support the existence of a recognizable biological substrate. A hypothesis that deserves further exploration is that possibly temperament is the determining endophenotype, while rapid cycling serves as an intermediate phenotype.3

Finally, although rapid cycling seems like a worsening in the course of bipolar disorder, it does not happen in a predictable manner. Rapid cycling seems to represent a transitory phenomenon rather than a stable phase or feature of the disorder in the majority of cases.3

Financial disclosure: Dr Dimellis has received honoraria from Janssen-Cilag, Eli Lilly, Pfizer, Servier, and AstraZeneca and is a member of the speakers/advisory boards for Janssen-Cilag, Eli Lilly, Pfizer, Servier, AstraZeneca, and Sanofi.

References

1. Fountoulakis KN, Akiskal HS. Focus on bipolar illness. CNS Spectr. 2008;13(9):762. PubMed

2. Fountoulakis KN, Kontis D, Gonda X, et al. Treatment of mixed bipolar states. Int J Neuropsychopharmacol. 2012;15(7):1015–1026. PubMed

3. Carvalho AF, Dimellis D, Gonda X, et al. Rapid cycling in bipolar disorder: a systematic review. J Clin Psychiatry. 2014;75(6):e578–586. Abstract

4. Kupka RW, Luckenbaugh DA, Post RM, et al. Rapid and non-rapid cycling bipolar disorder: a meta-analysis of clinical studies. J Clin Psychiatry. 2003;64(12):1483–1494. Abstract

5. Bauer MS, Whybrow PC, Winokur A. Rapid cycling bipolar affective disorder: I. Association with grade I hypothyroidism. Arch Gen Psychiatry. 1990;47(5):427–432. PubMed

Estrogen for Depressed Menopausal Women

The phases of a woman’s life are demarcated by points of transition in her reproductive cycle. Global shifts in the hormonal milieu accomplish the transitions from child to woman, woman to mother, and mother to elder.

The major hormones of the female reproductive cycle include estrogens (estrone, estradiol and estriol), progesterone, follicle-stimulating hormone (FSH), and luteinizing hormone (LH). The effects of these reproductive hormones on a woman’s mood are most prominent not at points of lowest or highest expression but rather at times of rapid change in serum concentration.1

The transition to menopause is accomplished over many years, beginning with gradual increases in the levels of FSH and LH while the woman maintains regular cycling. During perimenopause, menstrual cycles become intermittent, and, in the 6 months around the time of the final menstrual period, estrogen levels markedly decrease. A corresponding decline in FSH and LH quickly follows, ultimately resulting in stably low levels of all reproductive hormones in the postmenopausal period.2

An increase in risk for depressive symptoms occurs during the menopausal transition. Common symptoms of perimenopause like insomnia and vasomotor symptoms may be important contributors to low mood.3 The cessation of menstruation is not itself depressogenic, as depressive symptoms are reduced after the completion of menopause.4

Transdermal estradiol has been found effective for perimenopausal depression in randomized controlled trials.5 But, in accordance with the hypothesis that it is the rapid alteration in estrogen levels rather than low serum estrogen itself that predisposes perimenopausal women to depressive symptoms, treatment with estradiol alone appears less effective for depressed women who have completed menopause.6 However, estradiol treatment in postmenopausal women has been found to enhance7 or accelerate8 the effect of antidepressant treatment, resulting in improved global well-being and quality of life over and above that obtained with the antidepressant alone.9 Thus, combination of estrogen with an antidepressant can be an effective strategy that in some cases is greater than the sum of its parts.

Estrogen treatment has a positive effect on physiological symptoms associated with menopause.10 To some degree, the positive effect of estrogen on mood in perimenopausal women may be mediated by mitigation of physiological symptoms,3 but the extent of the interrelationship is not yet clear.

Potential adverse effects of estrogen replacement therapy in older women include increases in risk for the development of coronary heart disease, pulmonary embolism, and breast cancer.11 Combined treatment with estrogen and a progestin does not appear to mitigate these effects and may in fact increase breast cancer risk relative to use of estrogen alone.12

Thus, extended periods of hormone replacement therapy for postmenopausal women are not recommended and indeed are not indicated given the lack of effect of estrogen for depression after menopause. However, estrogen replacement therapy can be a reasonable short-term treatment for managing depressive as well as physiological symptoms associated with perimenopause. We suggest a treatment period of no longer than 6 months to cover the period of adjustment to the lower estrogen state while avoiding the multiple adverse effects associated with long-term use of hormone replacement therapy.

Financial disclosure: Dr Robakis has received grant/research support from NIMH. Dr Rasgon has received grant/research support and/or honoraria from and/or is a consultant for Magceutics, American Diabetes Association, Corcept, Shire, Sunovion, and Takeda.

References

1. Deecher D, Andree TH, Sloan D, et al. From menarche to menopause: exploring the underlying biology of depression in women experiencing hormonal changes. Psychoneuroendocrinology. 2008;33(1):3–17. PubMed

2. Rannevik G, Jeppsson S, Johnell O, et al. A longitudinal study of the perimenopausal transition: altered profiles of steroid and pituitary hormones, SHBG and bone mineral density. Maturitas. 1995;21(2):103–113. PubMed

3. Avis NE, Crawford S, Stellato R, et al. Longitudinal study of hormone levels and depression among women transitioning through menopause. Climacteric. 2001;4(3):243–249. PubMed

4. Freeman EW, Sammel MD, Liu L, et al. Hormones and menopausal status as predictors of depression in women in transition to menopause. Arch Gen Psychiatry, 2004;61(1):62–70. PubMed

5. Soares CN, Almeida OP, Joffe H, et al. Efficacy of estradiol for the treatment of depressive disorders in perimenopausal women: a double-blind, randomized, placebo-controlled trial. Arch Gen Psychiatry. 2001;58(6):529–534. PubMed

6. Morrison MF, Kallan MJ, Ten Have T, et al. Lack of efficacy of estradiol for depression in postmenopausal women: a randomized, controlled trial. Biol Psychiatry. 2004;55(4):406–412. PubMed

7. Schneider LS, Small GW, Hamilton SH, et al. Estrogen replacement and response to fluoxetine in a multicenter geriatric depression trial. Am J Geriatr Psychiatry. 1997;5(2):97–106. PubMed

8. Rasgon NL, Dunkin J, Fairbanks L, et al. Estrogen and response to sertraline in postmenopausal women with major depressive disorder: a pilot study. J Psychiatr Res. 2007;41(3–4):338–343. PubMed

9. Schneider LS, Small GW, Clary CM. Estrogen replacement therapy and antidepressant response to sertraline in older depressed women. Am J Geriatr Psychiatry. 2001;9(4):393–399. PubMed

10. Newton KM, Reed SD, LaCroix AZ, et al. Treatment of vasomotor symptoms of menopause with black cohosh, multibotanicals, soy, hormone therapy, or placebo: a randomized trial. Ann Internal Med. 2006;145(12):869–879. PubMed

11. Rossouw JE, Anderson GL, Prentice RL, et al. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women's Health Initiative randomized controlled trial. JAMA. 2002;288(3):321–333. PubMed

12. Bakken K, Fournier A, Lund E, et al. Menopausal hormone therapy and breast cancer risk: impact of different treatments. The European Prospective Investigation into Cancer and Nutrition. Int J Cancer. 2011;128(1):144–156. PubMed

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