Bipolar Disorder Screeners “Don’t Make the Diagnosis,” They Alert and Educate

In this podcast, taken from a live Q&A session at the March Psych Congress Regionals virtual meeting, Steering Committee Members, Rakesh Jain, MD, MPH, and Greg Mattingly, MD, discuss diagnosing bipolar disorder versus major depressive disorder (MDD) and attention-deficit/hyperactivity disorder (ADHD), bipolar disorder screeners best practices, and the realistic expectations when using screeners.

Saundra Jain, MA, PsyD, LPC, Adjunct Clinical Affiliate, University of Texas at Austin School of Nursing, moderates the discussion.

For more information on Psych Congress Regionals and to register, visit the event information page.

Read the transcript:

Dr Saundra Jain: So to get us started, let me welcome both Dr Jain and Dr Mattingly to Q&A this morning. Nice to be with you both and glad that you're with us. So I want you to know we've got some great questions, so let's just jump right in.

Greg, if I may, let me start with you. Several of our attendees, our clinicians, they want to know this.

While both of you emphasized ensuring that it is or is not major depressive disorder (MDD), what about the irritability, low frustration tolerance associated with MDD, where suddenly now everyone is bipolar and everyone is on a mood stabilizer? Should that be a concern with incorrectly attributing bipolar to irritated but depressed patients?

Dr Greg Mattingly: No Saundra, obviously it's the rookie mistake. Each of us had probably made it at one point or another, but I'll share a comment recently. I was driving home Rakesh, and I was listening to National Public Radio, and a reviewer there was talking about, he's a pediatric bipolar expert, and he said, "Oh, I know the child was bipolar because he was irritable."

I'm like, "Irritability does not define a diagnosis." You can be irritable with depression, you can be irritable with anxiety, you can be irritable with ADHD, that intermittent, explosive irritability you get when you're frustrated, you can be irritable with bipolar. So it is not diagnostic specific. It tends to be transdiagnostic.

So I agree with the questioners out there. Irritability is a symptom, it's not a diagnosis. It's not a hallmark for all of a sudden going on an atypical or a mood stabilizer. The question, as Rakesh has talked about, is what's the underlying condition? Because [inaudable] for each of those conditions are very specific.

Dr. Rakesh Jain: That's such a great point.

Saundra: Rakesh, how about you? Yeah, what might you add to what Greg said? Because I think this is a great question for discussion.

Rakesh: Yes. All 3 of our practicing clinicians have seen that error, not just in our own caseloads, but referrals that we received. By the way, first of all, good morning to all of my colleagues listening in this is our first Psych Congress [Regionals]. And you are starting this out with a bang. So welcome to the Psych Congress Regionals Series, as you heard Greg say, and it's a particularly important point that I would love to underline.

There are 3 symptoms that are highly sensitive, but not specific. And the acronym IDI really works well, Sandra. So irritability is a red flag, but that's all it takes. It's a red flag. The 'D' stands for distractibility. Don't let the tail wag the dog don't let that decide where the diagnosis is. So don't use that to differentiate the two conditions and the other 'I', IDI is insomnia.

So by all means pay respect to irritability, but that's all you want to do is pay respect to it. You do not want to let it determine the diagnosis. The only way to do that is we talked about it a little bit earlier is to use the DSM criteria.

Saundra: Beautifully stated. You know, I think also not only are clinicians misled by symptoms, being specific. Think about patients, I know you both have had this experience as have all of our attendees, patients will come in, they will have seen a special on bipolar disorder, and they will begin by saying, I am extremely distractible.

I did the self-check during the show, and I know that I have bipolar disorder and they've already got this mindset. So the burden is upon us to really be watchful of exactly what both you and Greg have described. Let's do this gentlemen, let's move on. I know that the 3 of us are really lovers and supporters of screening tools as a regular part of clinical practice.

And one of our viewers has a very specific question. So let me pose this one to you Rakesh, and then Greg, I'd love to hear your thoughts as well. So here we go. Would you use screening instruments to differentiate bipolar disorder from ADHD?

Rakesh: Maybe not differentiate because you know, screening tools don't make the diagnosis. They do something else though that's incredibly important, which is, alert the clinician, educate and alert the patient or the support system and allow us to do measurement-based care.

So I would not use it necessarily to say, "Okay, because this is what your scale says, thou shalt forever now not have bipolar disorder,” or "You do have bipolar disorder,” but having said that they can be incredibly alerting. So if you have a patient who on the [Mood Disorder Questionnaire] MDQ clearly demonstrates believably that they've never had a manic or a hypomanic episode, I think you can take it to the bank because the MDQ specificity, meaning its ability to exclude bipolar disorder, when the scale says it's not there, is about 96%, though the sensitivity isn't very high. As a result, the screeners ought to be exactly what they are, screeners, and should be used for that particular purpose. And Greg, I believe you and I share a very significant common passion for scales and screeners. So what would you say?

Greg: Rakesh you said it exactly right. A screener is meant to be a big net. I want to catch all the fish, but it doesn't tell you what kind of fish are in your net. So we're there to catch all the fish to make sure no fish get missed, but then you got to look through and say, "Okay, is this fish somebody with depression, ADHD, or is this really bipolar disorder?". I think the screeners, as you said, are highly educational. I have a lot of patients come in, Sandra, and they think, "Oh, I think I have ADHD. And maybe some depression." and all of a sudden they get to that one scale that's the MDQ and they said, "I have all of those symptoms. What's that scale?". So I think it can be educational. I think it's a great screening tool to bring a big net in, but then it's our job to look in that net and say, "Okay, exactly what type of fish am I dealing with here?".

Saundra: Yeah.

Rakesh: Love that metaphor. That's a great one that I hadn't heard before. And I just love it, Greg.

Saundra: I agree with you, Rakesh. We have about 2, well, actually we have a minute left. So I'm going to ask you both just to weigh in quickly on another scale.

And this is one of our attendees is saying, "Does the rapid mood screener have higher sensitivity and specificity than the two screeners that were discussed during the presentation?". Greg, may we start with you or Rakesh? Either.

Greg: Rakesh is the expert on this field. I think you're one of the co-authors on if I remember right. I've used it quite a bit. I think they're both pretty good screeners with, as we said, a big net, but they're not, once again, they're not always highly specific and Rakesh, go ahead and comment. I know you have the numbers on the back of your hand, as far as this.

Rakesh: Well, don't know about that, but I think you're completely right. These are instruments that are designed to alert the clinician in either direction, low chance of it being present, high chance of being present. So that's why the question from our audience member, which is, what is the sensitivity and specificity?

But a better question to ask, really, if you think about it is, what's the positive predictive value and what's the negative predictive value? And on both of those, the rapid mood screener does actually in fact beat the MDQ, but here's the thing, no matter which one you used, as long as you're measuring and using it to help you, you are a winner. So if you're interested in the rapid mood screener, they are actually in fact quite easily available for no charge on the internet.

Saundra: Perfect. Well, both of you Rakesh, Greg, I want to thank you for joining us this morning. I can't think of a better way to start our day one of our regional meeting.